ATR TEMPLATE

DYSFUNCTIONAL THOUGHT RECORD

1. Situation Who? What? When Where?

2. Moods a. What did you feel? b. Rate each mod (0-100%)

3. Automatic Thoughts (Images) a. What was going through your mind just before you started to feel this way? Any other thoughts? Images? b. Circle the Hot Thought.

4. Evidence That Supports the Hot Thought

5. Evidence That Does Not Support the Hot Thought

6. Alternative/Balanced Thoughts a. Write an alternative or balanced thought. b. Rate how much you believe in each alternative or balanced thought? (0-100%)

7. Rate Moods Now Rate moods listed in Column 2 as well as any new moods (0-100%)

Wednesday

night, 7:45

p.m. Just

got off the

phone

talking to

my

parents.

They told

me they

were

inviting my

sister to

come with

them when

they visit

tomorrow.

Anger

100%

Fear

100%

Abandoned

100%

Alone

100%

They know I don’t get

along with my sister.

They know I don’t really

want to see her.

They don’t care about

my feelings, aaaah.

They don’t love me.

This will never get

better.

I can’t tolerate the pain.

I need to stop this pain.

Image of cutting my

wrists.

I need a tranquilizer.

I don’t like these

feelings and I wish I

didn’t have them.

Cutting my wrists

helps the pain go

away.

Tranquilizers help

me feel calmer.

I have tolerated

more pain than this

in the past.

Cutting my wrists or

talking a tranquilizer

in the past has only

temporarily stopped

the emotional pain.

Cutting my wrists or

taking a tranquilizer

will not help me in

the family meeting

tomorrow.

Although I prefer to

deal with these

feelings, I have to

learn how sooner or

later. 45%

I might as well learn

while I am in the

hospital and

somewhat protected.

40%

I can take a

tranquilizer in one

hour if I haven’t

calmed down. 60%

Anger

100%

Fear

80%

Abandoned

90%

Alone

70%