The current worldwide outbreak of Coronavirus has become a global health concern (Shuja, Aqeel, Jaffar, & Ahmed, 2020). During COVID-19 two rules i.e. quarantine and isolation have been emerged to control the transmission of disease.
The recent studies also recommended the instructions to design online session’s relatable, enjoyable and engaging manner. The most effective points of organizing online session reported developing focused content, Aristotle triptych, emotional involvement, concise session and visual aesthetics. Alvi & Omrani (2019) postulated the effective 12 steps of online cognitive behaviour therapy which are listed below.
The 12 Steps for Online CBT
The twelve steps of online CBT sessions comprised of teaching.
1. What are depression and anxiety? In the first session, the clients must be informed about the course content and objectives of the session. For example, the course comprised of 12 sessions and homework or training material will be provided for practical implementation. The length of each session must be explained with expected slides number. The clients must be introduced with cognitive behaviour therapy and its implication. Discuss crises and possible human response and how human responses can be altered using CBT approaches. The common responses to any trauma and stressful situation results in depression and anxiety. Then engage a client in-home assignment and ask them to share their experience regarding depression or anxiety within the last one weak. After receiving client assignments and the clinician should provide his feedback (Alvi, & Omrani, 2019).
2. What is the five-part model? At the beginning of each session, the therapist must welcome back to their clients. The warm welcome helps in maintain the good rapport, as a result, the client feels safe and confident during the entire session. Apart from the warm welcome, each session must summarize the interaction or main idea of the previous session. For example in the first slides, the client can ask the client to take 2-3 minutes and think about the main idea of the previous session. Later on, the therapist should explain how COVID-19 is associated with depression and anxiety. After summing up the previous session, the therapist must provide an overview of the current session. The current session is about the five-part model and to elaborate it, animations and pictures must be used. The five-part model is comprised of five important parts of life such as feelings, thoughts, physical reactions, behaviour and environment. All these five parts of lie are connected and impart huge impact. For example how our thinking can change our behaviour or how behaviour changes can alter our environment. Understanding these five parts and their interrelation can help the client to understand and solve their problems (Alvi, & Omrani, 2019).
The five-step model example
What are the environmental changes?
Winter, summer and COVID-19
What are physical reactions to these environmental changes?
The physical reactions to environmental change are cold, sweating depression and anxiety.
How did you feel?
Anxious stressed, feared
How this affect behaviour?
Staying at home during cold or hot weather, avoid touching public places excessive anxiousness, irritable, anger
What thought come to your mind?
I’ll die, my beloved one will get contagion, my future is uncertain.
Then the client should be given homework for developing the five-part model for evaluating their thoughts feelings, behaviour, physical changes and environment. Finally, the therapist must provide valuable feedback to the clients.
3. The connection between thought, feeling and behaviour, environment and physical behaviour. After briefing the main idea of the previous session, the client must be informed about the connection between thoughts, feelings and behaviour. For-example how our thinking (I’ll die due to COVID-19), leads to our feelings (anxiousness) and behaviour (anger or sadness). The minor changes in thinking can lead to better behavioural physical and environmental consequences. The cycle between thoughts, feelings, behaviour physical behaviour and environment must be explained with numerous examples (Alvi, & Omrani, 2019).
4. Strategies to deal with anxiety, depression or stressful situation. After a welcome back and synthesizing the previous session, the brief introduction will be shared with the client about the current session. The client should for about the diverse ways to deal with a stressful situation. As it is not always possible to avoid or escape from the obnoxious situation, therefore they should learn how to face and keep themselves calm even when thighs are not in their favour. According to literature distraction and deep breathing are the two most effective techniques to reduce anxiety and stress. The client must be teaching the ways how they can keep themselves distracted to avoid depression or anxiety.
5. Understanding and rating our feelings and thoughts record. After initial interaction such as welcome back and summarizing the previous session, the client should introduce the agenda of the current session. The feelings and mood pre and post-assessment are very crucial to understand the effectiveness of the intervention. The client must be ensuring what they were experiencing before the treatment and how they are feeling right now. For example, before these sessions what were their thoughts about the present and future life due to COVID-19? What is the current status of their thoughts? For that, the client must be taught how to evaluate the intensity, frequency and duration of thoughts using the mood record form. The clients must be shown the record form and the therapist must fulfil the thought record form as a sample work. Later on, the client must be given an assignment for filling the first three columns (a situation, feeling, and automatic thoughts) of thought record form. The therapist must provide detailed feedback to ensure the accuracy of the data (Alvi, & Omrani, 2019).
6. What are automatic thoughts? After the welcome back and review of the previous session, the client must be introduced about the objectives, learning outcomes and introduction of the current session. The client should explain the role of automatic thoughts in our lives and this automatic thought are consistent with our feelings and behaviours. Practice multiple examples, to teach the clients the connection between situation, feeling automatic thought and mood rating. For example, a thought came to my mind that due to COVID-19 I felt extremely anxious about my academic career. As the three columns of the thought record form were practised in the previous session. Now assign the client home assignment to the client for filling the fourth column of the thought record. The clinician should provide detailed feedback on the home assignment (Alvi, & Omrani, 2019).
7. Activity scheduling. As usual, after a warm welcome and previewing of the previous lecture, the client must be introduced about the agenda o current session. They should be introduced about the activity schedule is the next column of thought record form. The client must be asked to rate their current mood using the rating scale between 0-100. Show them the activity scheduling record form which comprised of 8 days room record form. The client must be asked to log their entire week activity along with mood rating. This activity schedule might help them to understand the connection between their mood and activities. Furthermore, the client must be given the same home assignment to record their mood and activity log for the entire week. The client must provide extensive feedback to the client (Alvi, & Omrani, 2019).
8. What is evidence and how can it help us rate our thoughts and feelings? Following the fixed pattern of welcome and debriefing the previous session, the therapist should provide an overview of the current session. In this session, column four and five should be explained to the client. The fourth column comprised of writing down the evidence does not support the hot thought.
The fifth column comprised of stating the balanced or alternative thoughts. Both the columns would help the students to understand the reality either the thoughts support or conversely contradict their conclusions. At this stage, the role of the therapist would help the client to critically evaluate the evidence of their thoughts. For example, if a client has a fear of losing someone due to COVID-19 outbreak ‘he/she must ask himself question like this. Why am I think that way? I have had not been in such circumstances before. To find out the answer to such thoughts the client needs to ask themselves what are the evidence of these thoughts? Nothing bad has had happened before, therefore I should be hopeful and positive about the current situation. The client must be given the home assignments to practice more thought record practice. Then the clinicians or therapist should provide detailed feedback (Alvi, & Omrani, 2019).
9. What is alternative and balanced thinking? While the client must follow the session following the structured pattern and provide a brief intro for the new session. The clients must be introduced about the actual meaning and significance of balanced thoughts. Ask the client to think about any situation they have mentioned in record form and elaborate either it has any evidence for this thought or can it be replaced with a balanced thought. For example, if I have thought of dying due to COVID-19 spread.
10. Experiment on alternative thoughts. The session should be preview following the static pattern and the client must be introduced about the agenda of the new session. Considering the multiple situations the client must be taught to replace the painful thought to alternative or balanced thought. The homework assignment should also be given to the client and the therapist must provide extensive feedback (Alvi, & Omrani, 2019).
11. Action plan. In this session, the client must be informed that they have learned all the steps of CBT to reduce anxiety and depression due to COVID-19. Now it’s a time to take action plan and keep progress record for the problems ahead of time (Alvi, & Omrani, 2019).
12. Review. The client should consider a few problems and interpret his thought following all the steps such as five-part model, thought record, situation, feelings, automatic thoughts, evidence, alternative/balanced thinking, tare your mood action plan experiment and review.