Middle Phase

When a certain degree of psychomotor activation and cooperation has been achieved, use of the diary for monitoring automatic thoughts and cognitive restructuring, according to standard CT protocols, is introduced (Beck et al., 1979). During this second phase, cognitive strategies are mainly targeted to change mood and to inhibit central pleasure-reward mechanisms.

Patients are at first asked to identify situations that evoke discomfort and rate them on a scale from 0 to 100. Gradually patients should be encouraged to label their discomfort more specifically, using appropriate terms that better describe their emotions. Once they become familiar with identifying the situations and recognizing their emotions, we bring in the concept of automatic thoughts and ask subjects to start monitoring them and writing them down in the diary. Thinking errors are addressed as they arise in patients' reports. Finally, patients are asked to counteract their automatic thoughts with a more objective and rational point of view, and to add this last part to their diary. When discussing automatic thoughts and dysfunctional beliefs in session, it is important to start working with the most weakly held beliefs, which are less likely to induce resistance from patients and are therefore more amenable to change. Automatic thoughts are introduced only at a later stage, when patients have satisfactorily monitored their episodes of distress. Thus, patients are gradually exposed to the need for and cognitive restructuring with a self-disclosing strategy.

Behavioral homework is continued throughout this phase, and medication tapering is also initiated at the lowest possible rate (e.g., 25 mg of tricyclic antidepressant every other week). This phase may extend over 4-10 sessions until clinical improvement in mood occurs.

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