Appendix F

Therapist Worksheets
for In-Session and At-
Home Experiments

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
IDENTIFY BEHAVIOR-OUTCOME CONNECTIONS
IDENTIFY THE PATTERN OF INEFFECTIVE BEHAVIOR.

MY CURRENT BEHAVIOR (BEFORE THIS EXERCISE) MY PARTNER’S RESPONSE

Alternative behaviors (that might elicit a more desirable response):

______________________________________________________________________________

______________________________________________________________________________

(IF APPLICABLE, AFTER ROLE-PLAY PRACTICE, CIRCLE ALTERNATIVE BEHAVIORS THAT WORKED.)

This week I will practice the following:

______________________________________________________________________________

______________________________________________________________________________

BRING THIS WORKSHEET BACK NEXT SESSION WITH A FOLLOW-UP:

How did it work during the week?

______________________________________________________________________________

______________________________________________________________________________

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
COLLABORATIVE GOAL SETTING
Couple Goals

Individual Partner Goals for (name)____________________________________________________

Individual Partner Goals for (name)____________________________________________________

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
COLLABORATIVE PROBLEM-SOLVING WORKSHEET
Couple Contract for what purpose?___________________________________________
Step 1: Identify and clarify what the problem is.

Partner

______________________________________________________________________________

______________________________________________________________________________

Partner

______________________________________________________________________________

______________________________________________________________________________

Changes we hope to see or goals we hope to accomplish through our agreement:

Partner
______________________________________________________________________________

______________________________________________________________________________

Partner ___________________________________________________________________

______________________________________________________________________________

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
What each partner will do: When/under what How often? For how When to
circumstances: long? evaluate
this
agreement:

Name ________________________

Name ________________________

Notes:

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
INTIMACY-ORIENTED COMMUNICATION TRAINING FOR
COUPLES: THERAPIST’S WORKSHEET

Steps in Communication Training Tried it √ Worked √

Which partner?

• Therapist acknowledged _________’s feelings,

offers understanding
• Therapist offers alternative perspective for
_____________’s communication
• Intervene with _______________’s interpretations
o Intervention used:

• Collaborate with partners to establish realistic

communication goals
o What was addressed/offered?

• Behavioral guidance offered

o Suggestions offered:

• Behavioral rehearsal—Therapist modeled skill—

which?

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
REVERSE ROLES ROLE-PLAY:
IN-SESSION THERAPIST WORKSHEET
Therapist Steps in Reverse Role-Play Tried it √ Worked √

• Provide a rationale

• Collaborate with the couple to set up a scenario

• Sit quietly while couple engages in the role-play

• Check in and find out how each partner feels about his or
her part in the role-play

• Continue with the role-play, incorporating feedback from

the discussion

• Reverse back to normal roles and replay, incorporating

insights gained from the reverse roles role-play

• Guide post role-play discussion

• Give homework (that incorporates what the partners have

learned from the reverse roles role-play)

• Additional steps used:

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
GIVING DAYS WORKSHEET
Partner:

Date:

What I’d like to give to my partner: Feedback: Impact

of this gift on my
partner.
++ Very positive
+ Positive
0 Neutral, no impact
Today Next
Session

Circle any gifts that you will give your partner this week:

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
Created by Karen J. Prager, PhD, ABPP
© 2014 Taylor & Francis
WORKSHEET FOR EFFECTIVE SELF-EXPRESSION
Self-Expression Skills to Work on √
• Open communication about what is going on with me

• Communicating that I accept my partner as he or she is (or even

love him or her as he or she is) and his or her message to me

• Offering affirmations, compliments

• Offering reassurances to my partner

• Bringing up concerns in a way that leads to constructive

communication and problem solving

• Expressing needs, wants without criticizing

• Demonstrate my respect for my partner (does my partner

complain that I don’t show him or her respect?)

• Ask for or stand up for my own needs, wants, and values; be

assertive

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
EFFECTIVE SELF-EXPRESSION: THERAPIST WORKSHEET
Client’s Name:_______________________________________

Targeted Communication Goal:

Intervention Steps Accomplished: Tried it Worked

• Model skill

• Explain skill

• Role-play practice

• Feedback session

• Repeat

Targeted Communication Goal:

Intervention Steps Accomplished: Tried it Worked

• Model skill

• Explain skill

• Role-play practice

• Feedback session

• Repeat

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
WORKSHEET FOR IMPROVING LISTENING SKILLS
Listening Skill(s) for Me to Work on: √
• Listen quietly without interrupting

• Be attentive, show interest

• Listen actively to show I understand my partner’s

communication: Ask open-ended questions, paraphrase, reflect
feelings

• Monitor my interpretations of my partner’s words

o Does my partner occasionally or frequently tell me that I

am misunderstanding his or her meaning or intentions?

o Are there any interpretations I make of my partner’s

words that seem to cause me trouble (or trouble us as a
couple)? Please list some here.

• Keep myself calm about what my partner is saying to me

o What works so far to help me stay calm?

• Additional goals

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
LISTENING SKILL TRAINING: THERAPIST WORKSHEET
Listening Skill Focus for Intervention:

Intervention Steps Accomplished: Tried it Worked

• Model skill

• Explain skill

• Role-play practice

• Feedback session

• Repeat

Listening Skill Focus for Intervention:

Intervention Steps Accomplished: Tried it Worked

• Model skill

• Explain skill

• Role-play practice

• Feedback session

• Repeat

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
EMOTION REGULATION TRAINING:
THERAPIST’S WORKSHEET

Intervention Tried it Worked

Step

• Empower the client when introducing the training

How shall it be or how was it framed?

• Identify the most troubling emotion

• Identify and validate healthy goals associated with the current

functioning (e.g., normalize them as part of intimacy regulation)

• Identify alternative, more adaptive strategies for emotion

management (brainstorming process)

• Test the alternatives—as homework; client tries out one or more

strategies
Which?

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
DUAL MONITORING FORM
Partner’s
Internal Observations of My Interpretation of My My Immediate Is My Interpretation Internal Feedback
State Partner—What I See, Partner’s Behavior Goal/My Long- Helping Me to State and Subsequent
Emotion What I Hear? (Automatic Term Goal: Achieve My Goal? Emotio Interpretation:
1–10: Thoughts): Alternative n
Interpretation? 1–10:

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
SELF-SOOTHING TRAINING: THERAPIST’S WORKSHEET
Intervention Tried it √ Worked √

Step

• THERAPIST SOOTHES

• Therapist soothes ___________________ as he or she becomes

more anxious or angry (circle one), or as he or she tries
some new behavior (circle one)
• Therapist soothes ___________________ as he or she becomes
more anxious or angry (circle one), or as he or she tries
some new behavior (circle one)
• SELF-SOOTHING TECHNIQUES

• Progressive relaxation

• Three-part breathing

• Ujjayi breathing

• Self-soothing with the five senses—best senses to work with

(circle as many as were tried)
o Vision
o Hearing
o Smelling
o Touching
o Tasting
• Soothing self-talk—list self-statements tried

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
TRAINING TO INCREASE EMOTION TOLERANCE:
THERAPIST’S WORKSHEET
Intervention Tried it √ Worked √

Step

• Stop defensive behavior and encourage inward emotion focus

• Encourage client to label and stay focused on the emotion

• Encourage the client to accept the emotion and to accept him- or

herself with the emotion

Notes:

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
SELF-EMPOWERMENT TRAINING: THERAPIST’S WORKSHEET
Intervention Step Tried it √ Worked √

 Therapist Persuasions: Letting go of blame in favor of self-

empowerment
o You’ll feel less upset.
o You’ll feel competent in your relationship with your
partner just as your other roles and relationships are
competent.
o You can feel yourself to be a fellow traveler in life with
your partner instead of feeling one down.
o You can work on yourself and avoid the frustration of
attempting the impossible—changing your partner.
o You’ll gain benefits even if you two don’t stay together.
o Other persuasion

 Self-Empowering Interventions:
o Teach pause before speaking

o Model empowered responses

o Teach cognitive self-soothing—soothing self-talk

o Affirm empowered self-schema

o Help client create cognitive dissonance about old,

disempowered self-schema

o Use the “so-what” technique with an “I am too fragile”

schema

o Work with client to change negative self-schema

o Work with client to change unrealistic partner schemas

(e.g., My partner has all the power)

o Acceptance training: Encourage self and partner

acceptance

o Teach self-expression and listening skills

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
SELF-EXPRESSION WORKSHEET FOR BUILDING NEW
RELATIONSHIPS
Self-disclosure and active listening are great skills to learn for meeting and getting
to know new people. People who hesitate to share themselves often say that they were not
“raised that way,” meaning that they rarely heard people in their families talk about
personal, private things that they had on their mind to an empathic, caring listener. As a
result, you may feel clumsy or awkward or nervous when it comes to opening up about
yourself, expressing warm feelings, or giving others the gift of attentive listening.

Fill out this Checklist of Intimacy Concerns. It will get the ball rolling on helping you

to make more rewarding connections with other people. Score yourself on the reverse of

this form.

Check each of the statements below that applies to you.

___1. I sometimes fear that the other person will discover things about me that are
undesirable, bad, or shameful.

___2. I sometimes fear that the other person will abandon me if he or she knows my deepest
thoughts, either by leaving me, withdrawing his or her affection, or betraying me.

___3. I sometimes fear that the other person will use personal things he or she knows about
me against me, to hurt me.

___4. I sometimes fear that the other person will tell my secrets to others.

___5. I am sometimes bothered by feeling more emotional with the other person than with
other people.

___6. I am sometimes bothered by the fact that I can’t stay calm and rational when talking
with the other person.

___7. I am sometimes afraid of what I might say or do if I let my feelings out with the other
person.

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis
__8. Sometimes I’m afraid my partner will make me feel guilty about my true desires and
feelings.

___9. Sometimes I’m afraid my partner will get angry if I share my true desires and feelings.

___10. Sometimes I don’t want to hear what my partner has to say because I know he or she
wants me to do something I don’t want to do.

Things to keep in mind that will help you reach out to others despite your concerns:

1. Failing to talk about myself in a meaningful, intimate way is likely to continue being

a barrier to forming meaningful relationships.

2. Increasing my skill and comfort with intimate communication makes social

interactions and eventually, relationships, more enjoyable.

3. Warm, open communication can result in each person feeling accepted, affirmed,

validated, and cared for.

Created by Karen J. Prager, PhD, ABPP

© 2014 Taylor & Francis