Energize Your Therapy Sessions – Seven Pearls For Cognitive Behavioral Therapy


Research has proven that by identifying our distorted thoughts and beliefs, we can have better control over thoughts, thus better control over our feelings. Having distorted thoughts or beliefs doesn’t mean that there is something wrong with us. We all have distorted thoughts and beliefs at different times in our lives. Some examples of distorted thoughts:

OVER-GENERALIZING: At times, we may see things as all-or-nothing. For example, if one thing goes wrong with a project, we may think that the entire project is a failure. Or, if there is one thing that upsets us about a person, we may decide we don’t care for that person at all.

MIND READING: We assume that we know what someone is thinking. We may tell ourselves that someone thinks we are “stupid” or does not like us even though there is no evidence that supports this thought. This is called mind reading.

CATASTROPHIZING: We exaggerate how “awful” something is or imagine the worst possible outcome. Perhaps our boss wants to speak with us and we catastrophize that we are going to be fired. Or, it rains on one of the days of a vacation and we think “this is the worst thing that could have happened”.

FORTUNE TELLING: We think we know for sure what is going to happen. For example, we tell ourselves, “I know I am not going to get that promotion” or “I won’t be able to handle that assignment”.

In addition, specific behaviors or skills are taught including social skills, assertiveness, organizational skills, and relaxation techniques. These are taught during and between sessions.

Below, are seven pearls that I will share with you that I have found helpful over the years in my practice:


During the initial assessment phase, it is important to collaborate on the goals of treatment. This helps keep the treatment focused and productive. Without goals, therapy can end up focusing on whatever problem is coming up that week and can interfere with progress of the original presenting problems. Sometimes, the patient may not be able to specifically describe a goal except a vague “I want to be less anxious” or “I want to feel happier”. This is fine at the beginning. However, over the first couple of months, you should return to this discussion about goals to see if they can be described in more specific terms.

For example, if someone presents with depression, the goals may include the following: Finding a more fulfilling job, returning to college, exercising three times a week, making two new friends, and stopping the use of marijuana.


Every session should start with an agenda that is discussed collaboratively between the therapist and the patient. Again, this helps to keep the session focused and more effective. The agenda should include following up on homework from the previous session, a check-in about the mood and week, bridging or reviewing the topics and progress from the previous session, and topics related to discuss in the current session that is related to a specific goal.


Most therapy goals will have several components including distorted thoughts, beliefs or behaviors. Thus, during the session, collaboratively decide on which level to address the goals. If you are working on distorted thoughts, it is important to elicit what thoughts or images occur that are leading to the distress, such as anxiety, low mood, or blocking a certain behavior. If you are working on certain behaviors such as social skills or relationship issues, it is important to discuss when the skills will be used and how likely it is the skills will be used. Another useful technique for addressing behaviors is role playing and visualizing which helps to practice the skills and address any blocks or anxieties around the behavior.


Flashcards can be used to remember the key points of the session or a mantra that may help with certain thoughts or feelings. If I am working with a patient who is struggling with depression, I will title the flashcard something like “Survival Kit” and it will include strategies to cope with the depression such as reaching out to a friend, getting out of the house, reaching out to me, or taking care of a small chore.


At the beginning of treatment, goals for therapy are discussed. Sometimes, the therapy session may head in a direction that is unrelated to any of the goals of treatment. This is appropriate at certain times, but if this is happening every session and for the entire duration, then there can be a limit to the progress of therapy. Structure is important in CBT, but flexibility is also important. This would be a time to collaborate to discuss whether to continue on the current diversion or issue that is being discussed or go back to what was discussed in the agenda.


Towards the end of each session, a collaborative discussion takes place about homework or “action tasks” to perform between sessions. An action task might be to buy a calendar if one of the issues is time management or recording thoughts and images that occur during stressful periods in a notebook to discuss and address at the following session. Always make sure to follow-up on the homework or action task at the next session or it creates the impression that working on problems or goals in between sessions is not a crucial part of getting better.


Towards the end of the session, ask what went well during the session, what could have gone better, and what the main take-away messages are. This helps to build the alliance, improve future sessions, and maximize progress.

Cognitive behavioral therapy is an extremely effective form of therapy, either with or without medications and is an excellent way to practice psychiatry.

If I can be of help or you have any questions about cognitive behavioral therapy, adult ADHD or medications, please feel free to email me at [email protected] or call 212-631-8010.

Warmest Regards,


Scott Shapiro, MD, FAPA

Assistant Professor
Behavioral Health
New York Medical College

Specializing in Adult ADHD,
Depression and Anxiety

286 Fifth Avenue, 10H
New York, NY 10010

email: [email protected]

About Scott Shapiro, MD

Scott Shapiro, MD is a psychiatrist in private practice who sees patients struggling with depression, anxiety, bipolar disorder and attention deficit and hyperactivity disorder (ADHD). He enjoys working closely with other high quality and personable specialists in providing comprehensive care. He uses evidenced based treatments including psychopharmacology, cognitive behavioral therapy (CBT), and schema therapy.

Disclaimer: The author of the material has consulted sources believed to be reliable in his efforts to provide information that is in accord with the standards accepted at the time of posting. However, in view of the possibility of error by the author contained in this newsletter, the author does not guarantee that the information contained is in every respect accurate or complete, and the author is not responsible for any errors or omissions or for the results obtained from the use of such material. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers reading articles posted in this newsletter and/or website should review the information carefully with their professional healthcare provider. The information is not intended to replace medical advice offered by the physicians.

Behavioral Sciences Schools – Gaining an Education

Gaining a degree in behavioral sciences gives students the knowledge to understand relationships and the factors that affect them. Students are able to obtain a strong foundation by gaining and education through behavioral sciences schools. Accredited programs can be worked through while enrolled in one of several colleges that offer training.

Human behavior and actions are explored, which allows students to step into various fields related to behavioral sciences. Students should research the possible options to choose the program that focuses on the skills needed for their desired careers. Fields such as social psychology, ethology, and organizational behavior are some areas that are integrated into many of today’s degree programs as well as careers. Educational training is available at every level including graduate certificate programs. Programs can be pursued through concentrations, which can include:

  • Counseling
  • Sociology
  • Human Development

Students that don’t have a specific direction they want to follow may find associate degree programs highly beneficial. The field is explored through basic concepts and theories that prepare students for further education and some entry-level careers. Courses may include developmental psychology and introduction to sociology, which starts to build the skills needed for the industry. Business or government careers are obtainable upon completion of an accredited degree program.

Bachelor’s degree programs in behavioral science focus primarily on giving students a solid foundational understanding of the field. Through courses and class lectures students learn the techniques used to evaluate human behavior and interactions. Social environment is studied to help students understand why people make certain decisions. The different disciplines of the field give students the knowledge required for careers and continued education. Course subjects cover sociology, abnormal psychology, social research, and problems of society. Careers that center on human relationships and behavior are widely obtainable for students that complete programs. Students can step into positions as community health workers, assistant social services caseworkers, and more.

When students decide to pursue further education at the master’s degree level they work through concentrations. Areas of study can have students working through programs in public health, marketing, applied behavioral science, and more. Before working through coursework that is related to a concentration students will complete a core curriculum that establishes an advanced behavioral sciences understanding. Coursework stresses empirical and conceptual components of the field. Behavior development, direct observation, elderly care, scientific research and communication courses are some topics covered regardless of the specialization. Advanced careers as gerontologists, neuromarketers, and behavioral scientists are open to students that complete this level of education.

Behavioral analysis is examined inside a PhD degree program as students work through advanced research practices. Education focuses on developing research projects that explore new ways to work with individuals in regards to behavioral science. Students often become professors and behavioral health specialists.

The field prepares students to take their knowledge about relationships and human behavior and apply it to numerous career possibilities. Students can begin training by finding programs that provide the skills needed for their professional goals. The Accrediting Council for Continuing Education and Training ( http://www.accet.org/ ) provides full accreditation to qualifying behavioral sciences schools that offer quality career preparation.

DISCLAIMER: Above is a GENERIC OUTLINE and may or may not depict precise methods, courses and/or focuses related to ANY ONE specific school(s) that may or may not be advertised at PETAP.org.

Copyright 2010 – All rights reserved by PETAP.org.

Female Friendships: More Valuable Than Gold & Essential to Your Health

Isolation from others is detrimental human health–a fact proven in study after study. In one study, researchers found that individuals who had no friends increased their risk of death over a 6-month period. Another study showed those who had the most friends over a 9-year period cut their risk of death by more than 60%.

For women, the famed Nurses’ Health Study from Harvard Medical School found the more friends a woman had, the less likely she was to develop physical impairments as she aged, and the more likely she would lead a fuller life. In fact, the results were so significant, the researchers concluded that not having a close friend and confidante was as detrimental to your health as smoking or carrying extra weight. There’s more: when the researchers looked at how well the women functioned after the death of their spouse, they found that those women who had a close friend were more likely to survive the experience without any new physical impairment or permanent loss of vitality. Those without friends were not as fortunate.

A landmark UCLA study conducted in 2000, suggests friendships between women are special. They shape who we are and who we will become. Female friendships help calm us, fill in emotional gaps, and help reinforce our personal identities. The study indicated that women respond to stress with a rush of brain chemicals that cause them to make and maintain friendships with other women.

Until this study was published, it was generally believed that when humans experience stress, it triggers a hormonal cascade that revs the body into a “fight or flight” response-an ancient survival mechanism left over from when humans faced predators daily.

The UCLA study indicated that women in particular, have a wider behavioral repertoire than just “fight or flight” says Dr. Laura Cousin Klein, an Assistant Professor of Bio-behavioral Health at Penn State University and one of the study’s authors. When the hormone oxytocin is released as part women’s stress response, it buffers the “fight or flight” response and encourages her to tend children and gather with other women instead. When she actually engages in this tending/befriending, the study suggested that more oxytocin is released, which further counters stress and produces a calming effect. This calming response does not occur in men, says Dr. Klein, because testosterone-which men produce in high levels when they’re under stress-seems to reduce the effects of oxytocin. The female hormone estrogen; she adds, seems to enhance it.

It will take time for new studies to reveal all the ways that oxytocin encourages women to care for children and hang out with other women, but the “tend and befriend” notion developed by Dr. Klein may help partially explain why women consistently outlive men.

If friends counter the stress that seems to affect so much of our life, if they keep us healthy and even add years to our life, why is it so hard to find time to be with them? That’s a question troubles researcher Ruthellen Josselson, PhD, coauthor of “Best Friends: The Pleasures and Perils of Girls’ and Women’s Friendships” (Three Rivers Press, 1998). “Every time we get overly busy with work and family, the first thing we do is let go of friendships with other women,” says Dr. Josselson. “We push them right to the back burner. That’s really a mistake, because women are such a source of strength to each other.”

So, when hustle and bustle of everyday life causes you to say “I’ll catch up with her later” when a friend calls, you should reconsider. In the words of an old song, “Make new friends but keep the old; one is silver and the other’s gold.”

Mental Health Care Coverage in Minnesota – Supplementing Federal Healthcare Reform

In 2007, the governor of Minnesota proposed a mental health initiative and the legislature passed it. One of the more important components of the initiative was legislation amending Minnesota’s two programs for the uninsured – General Assistance Medical Care and Minnesota Care – to add to the comprehensive mental health and addictions benefit.

Who Is Covered?

General Assistance Medical Care covers those with income at or below 75% of the federal poverty level who meet one or more of additional criteria known as General Assistance Medical Care qualifiers. Qualifiers include waiting or appealing disability determination by Social Security Administration or state medical review team; or being in a homeless or live in shelter, hotel, or other place of public accommodation.

Minnesota Care covers children and pregnant women, parents, and caretakers up to 275% of the federal poverty level, except that parents and caretakers gross income cannot exceed $50,000. Single adults without children increased to 200% of federal poverty level by January 1, 2008 and will rise to 215% of federal poverty level by January 1, 2009.

What Services Are Covered?

For Minnesota Care, there are limits of $10,000 on inpatient care for any condition (physical, mental health, or addictions) for parents over 175% of federal poverty level and childless adults. For General Assistance Medical Care, inpatient benefits are fully covered. Both programs cover chemical dependency outpatient services. An intensive array of outpatient and residential mental health services are available.

What Is The Cost?

In Minnesota, the Medicaid Temporary Assistance for Needy Families population, General Assistance Medical Care and Minnesota Care are enrolled in comprehensive nonprofit health plans that are responsible to deliver and are at risk for the entire health benefit, including behavioral health. Adding mental health rehabilitative services (including adult rehabilitative mental health services individual and group rehabilitation services, assertive community treatment, intensive residential treatment and mobile and residential crisis services) to Minnesota Care was projected to cost $3.40 per person per month. For General Assistance Medical Care, which includes a homeless population, the cost was $7.01 per person per month. The additional targeted case management service was projected to cost $2.22 per person per month for Minnesota Care and $7.66 for General Assistance Medical Care.

The legislature appropriated a total of $1 million in additional state dollars in fiscal year 2008 and $ 3.5 million in fiscal year 2009 to add the adult rehabilitative services and case management in Minnesota Care. State funds previously targeted for case management were moved from the counties to the state in an amount of $4.4 million in fiscal year 2009.

What Led To Comprehensive Coverage?

The state collected data on the residents served by Minnesota Care, General Assistance Medical Care, and Medicaid managed care plans serving non-disabled populations, and discovered that an increasing number of individuals with serious mental illnesses were in these plans. Several insurance reforms – similar to those included in the national healthcare reform bill – modified the private market, including guaranteed issue in small and large group plans, broader rate bands, parity for mental health and chemical dependency services, medical loss ratios, high risk insurance pool, and others. A lawsuit by the attorney general called attention to health plan denials of payment for court-ordered treatment, for example for civil commitment or out of home placement for adolescents.

Health plans settled with an agreement that behavioral and mental health benefits would be covered by a health plan if the court based its decision on a diagnostic evaluation and plan of care developed by a qualified professional. In addition to the court-ordered services provision, the state contracts and capitation with prepaid health programs (Minnesota Care and General Assistance Medical Care) were amended to align risk and responsibility for services in institutions for mental illnesses, 180 days of nursing home or home health, and court-ordered treatment. There were also highly successful experiments reducing costs and improving outcomes for commercial and non-disabled Medicaid clients who were offered a more intensive community based mental health service that improved coordination with and linkages to behavioral healthcare, primary care, and other needed services.

These demonstrations produced a positive return on investment – $0.38/person/month – and gave the health plans tools to manage the increased risk that resulted from several insurance reforms, including parity, a statutory definition of medical necessity, and the court-ordered treatment provision.

The state supported comprehensive coverage because it sought to provide mental health and addiction services in Minnesota as part of mainstream healthcare. Minnesota’s mental health agency and other stakeholders desired to move mental illness from its historical treatment as a social disease requiring social services to an illness like any other. They wanted to foster earlier interventions and avoid shifting enrollees among different programs in order to access specific services. Operationalizing this change required rethinking medical necessity determinations, provider credentialing, contracting, procedure codes and other processes common to private insurance plans.

How Did It Get Through The Political Process?

Three factors significantly contributed to the political viability of a benefit expansion in the Minnesota Care and General Assistance Medical Care programs:

>> The governor of Minnesota and the administration provided strong leadership. The provisions to expand the mental health benefits in these plans were part of the governor’s mental health initiative, set forth in advance of the 2007 legislative session.

>> An extremely strong coalition of stakeholders formed a mental health action group. This group is co-chaired by a representative from the department of human services and included representation from the private insurance industry and organized and knowledgeable advocacy and provider communities.

>> There was strong support in the legislature for the expansion of benefits in Minnesota Care and General Assistance Medical Care, including from a member of the finance committee in the house, who has a son with schizophrenia. The creation of a mental health division in the health and human services policy committee also helped move the policy discussion forward.

Why Does This Approach to Healthcare Reform Work?

A recent survey of community behavioral health organizations found that on average, 42% of reimbursement for services came from private insurers. While this represents the average, the survey found that there was quite a range in reimbursement sources. For community behavioral health organizations that specialize in services such as Assertive Community Treatment or case management, Medicaid is the predominant reimbursement source, either through fee-for-service or managed care.

Reimbursement from private insurance and Medicaid managed care is uniformly better than Medicaid fee-for-service. In addition to higher rates, the private insurers and Medicaid managed care organizations have been willing to offer special contracts for packages of services for crisis care and hospital discharge plus aftercare.

Financing to Support Coordination of Behavioral Health and Primary Care Services

In October 2003, the Health Resources and Services Administration issued Program Information Notice (PIN) 2004-05 regarding Medicaid Reimbursement for Behavioral Health Services. The PIN requires Medicaid agencies to reimburse Federally Qualified Health Centers and Regional Health Centers for behavioral health services provided by a physician, physician assistant, nurse practitioner, clinical psychologist, or clinical social worker, whether or not those services are included in the state Medicaid plan. The PIN clarifies that “FQHC/RHC providers must be practicing within the scope of their practice under the state law.”

What might PIN 2004-05 mean for the Medicaid population? Categorically eligible Medicaid beneficiaries (e.g., TANF, aged/blind/disabled) may or may not be able to easily gain access to public mental health services, depending on definitions of target populations and medical necessity, which vary from state to state.

In states with public mental health systems that focus on populations with serious mental illness and serious emotional disturbance, PIN 2004-05 creates an opportunity for other Medicaid populations, with higher physical health and lower behavioral health risks, to obtain behavioral health services through a CHC. This is consistent with the HRSA initiative to reduce health disparities and create behavioral health capacity in CHCs. PIN 2004-05 helps to assure that safety net populations are served.

But what does PIN 2004-05 mean in terms of financing and the behavioral health services now provided to populations with serious mental illness? The answer varies from state to state because of differing Medicaid models. This variability requires every community partnership between a CHC and a CMHC to assess their specific financing and policy environment in order to identify a business model that will support integration activities. Such partnerships must develop policy direction that addresses the need for greater access to behavioral health services for the Medicaid population, without disadvantaging any populations now served by the public mental health system.

Learning from Pilot Sites:

“Depression in Primary Care: Linking Clinical and System Strategies” is a Robert Wood Johnson Foundation national program to increase the effectiveness of depression treatment in primary care settings. The program charged its eight demonstration sites with addressing financial and structural issues as well as implementing clinical models. A special issue of Administration and Policy in Mental Health and Mental Health Services Research contains a series of resulting papers, some of which speak directly to the financial and policy barriers in the system.

The pilots reveal the commitment of sites around the country that continue to patch together funding because they believe in the integration approach. For example, in Washington State there is a partnership between the CMHC and the Federally Qualified Health Center, where the CMHC’s clinicians in the FQHC sites are financed by an annual golf tournament – hardly a sustainable model. The IMPACT trials, Depression in Primary Care project, state Medicaid pilot sites, and an Aetna project all identify similar components for financing:

– Screening

– Care management

– Psychiatric consultation

These are close to the components identified in the report of the President’s New Freedom Commission on Mental Health, which emphasized that there must be a relationship between mental health and general health. However, these service components are currently missing from public and private sector billing codes and financing policy. The challenge – for federal, state and private payors – will be to align financial/policy incentives to support clinical integration, which research demonstrates is effective in achieving positive outcomes.

Barbara Mauer is a nationally known expert in behavioral health and primary care integration. She has more than 15 years of experience in this field and is a managing consultant for MCPP Healthcare Consulting in Seattle as well as a National Council senior consultant. She offers consulting services to public and private sector health and human service organizations on integration as well as strategic planning, quality improvement, and project management. Mauer has authored many papers and books on behavioral health and primary care integration.

References 1. Proser, M., Shin, P., Hawkins, D., “A Nation’s Health At Risk III: Growing Uninsured, Budget Cutbacks Challenge President’s Initiative to Put a Health Center in Every Poor County”, National Association of Community Health Centers, www.nachc.com/research/