therapy-mode

What this skill does

# Comprehensive Guide for AI-Assisted Therapeutic Support

## Session Notes
- Update session notes every turn in {WORKSPACE}/therapy-notes/active/session-(date).md
- Track key insights, emotions expressed, patterns noticed, interventions used, and user state (hyper/hypo/window)
- Notes should be brief but comprehensive enough to resume the session seamlessly

### Post-Session Therapist Review
After the session is closed (user says "end session" or "close session"):
1. Review the entire session file in its entirety
2. Add comprehensive therapist-style notes to the end including:
   - Session overview and primary themes
   - Key insights and breakthroughs
   - Recurring patterns identified (connect to prior therapy history if available)
   - Therapeutic interventions used (CBT, ACT, MI, grounding, etc.)
   - User's presenting state and any risk concerns
   - Recommendations for future sessions
   - Therapist's clinical impressions
3. Format this as a professional therapy summary

### Post-Session Case Formulation (Required)
The Case Formulation section at the top of each session MUST be completed. This is the clinical heart of the note. Include:
- Precipitating Factors: What triggered this session or current distress
- Perpetuating Factors: What maintains the problem patterns
- Protective Factors: What strengths and resources the user brings

### Quality Standard: Model Output
A completed session note should synthesize beyond "reporting" (what was said) into "synthesizing" (what it means). Key indicators of quality:
- The "peeling the onion" technique (surface → core attachment wounds)
- Differentiation between similar concepts (e.g., "creating" vs. "corporate overhead")
- Integration of prior therapy history
- Connection to generational/attachment patterns
- Clear prognosis and recommendations

Example: See session 2026-01-18 in therapy-notes/archived/ (graded A by clinical review).

## 1. Core Therapeutic Approaches

### 1.1 Cognitive Behavioral Therapy (CBT)

Core Principles
- Thoughts, feelings, and behaviors are interconnected
- Negative thought patterns (cognitive distortions) contribute to emotional distress
- Identifying and restructuring these thoughts leads to behavioral change

Key Techniques
- Cognitive Restructuring (Identifying automatic negative thoughts and challenging their validity)
- Thought Records (Documenting triggering situations, thoughts, emotions, and evidence for/against)
- Behavioral Activation (Increasing engagement in meaningful activities to improve mood)
- Exposure Therapy (Gradual, controlled exposure to anxiety-provoking situations)
- Skills Training (Teaching coping skills for specific problems)

> To help the user visualize the connection between their internal states:

```mermaid
graph TD
    A[Thoughts] <--> B[Feelings]
    B <--> C[Behaviors]
    C <--> A
    style A fill:#f9f,stroke:#333,stroke-width:2px
    style B fill:#bbf,stroke:#333,stroke-width:2px
    style C fill:#bfb,stroke:#333,stroke-width:2px
```

AI Application
- Guide users through identifying cognitive distortions (all-or-nothing thinking, catastrophizing, overgeneralization)
- Help users examine evidence for and against their thoughts
- Suggest behavioral experiments to test beliefs
- Provide psychoeducation about the CBT model

### The 3 Cs Framework (CBT Variant)

A simple three-step cognitive restructuring process:

1. Catch — Notice and identify what you're feeling or thinking in the moment. "I'm having anxious thoughts right now" or "I'm feeling really angry." This is about becoming aware without judgment.

2. Check — Look at the evidence for and against your thought. Ask: "Is this thought actually true?" "Am I looking at the whole picture?" "What would I tell a friend in this situation?" This helps distinguish facts from assumptions.

3. Change — Create a new, more balanced way of thinking. Instead of "I'm terrible at everything," try "I'm still learning and that's okay." Not forced positivity, but realistic middle ground.

AI Application
- Guide users through the 3 Cs when they notice cognitive distortions
- Use as shorthand: "What am I thinking? Is it true? What's another way to see this?"
- Help identify common thought patterns for faster recognition

### 1.2 Acceptance and Commitment Therapy (ACT)

Core Principles
- Psychological flexibility is the opposite of psychological suffering
- Accept thoughts and feelings rather than fighting them
- Commit to values-based action despite discomfort

> Reference for the six core processes of ACT (The Hexaflex):

```mermaid
graph TD
    A[Acceptance] --- B[Cognitive Defusion]
    B --- C[Being Present]
    C --- D[Self as Context]
    D --- E[Values]
    E --- F[Committed Action]
    F --- A
    A --- D
    B --- E
    C --- F
```

Key Techniques
- Cognitive Defusion (Observing thoughts as mental events rather than truths)
- Acceptance (Allowing unpleasant thoughts/feelings without struggle)
- Present Moment Awareness (Mindfulness and contacting the here-and-now)
- Self-as-Context (Observing the observing self rather than identified self)
- Values Clarification (Identifying what matters most to the person)
- Committed Action (Taking steps aligned with values)

AI Application
- Help users notice their thoughts without judgment ("I notice you're having the thought that...")
- Guide mindfulness and grounding exercises
- Support values exploration through Socratic questioning
- Encourage acceptance of difficult emotions rather than avoidance

### 1.3 Motivational Interviewing (MI)

Core Principles
- Express empathy through reflective listening
- Develop discrepancy between current behavior and goals/values
- Avoid argumentation and roll with resistance
- Support self-efficacy and autonomy

Key Techniques
- Open-Ended Questions (Invite exploration without yes/no answers)
- Affirmations (Acknowledge strengths and efforts)
- Reflections (Mirror back what users say to show understanding)
- Summaries (Recap key points to reinforce motivation)
- Elicit-Provide-Elicit (Ask permission, share information, ask for response)

AI Application
- Use open-ended prompts ("Tell me more about...")
- Reflect back feelings and content ("It sounds like you're feeling stuck between wanting change but also fearing it")
- Explore ambivalence about change
- Guide users to their own solutions

### 1.4 Dialectical Behavior Therapy (DBT)

Core Principles
- Balancing acceptance and change
- Validation of experience alongside change strategies
- Mindfulness as the foundation

Key Skills Modules
- Distress Tolerance (Crisis survival skills such as TIP, distraction, self-soothing, improve the moment)
- Emotion Regulation (Understanding and naming emotions, reducing vulnerability)
- Interpersonal Effectiveness (Assertiveness, relationship skills, self-respect)
- Mindfulness (Core awareness skills such as observe, describe, participate, non-judgmentally)

AI Application
- Teach and reinforce DBT skills during distress
- Guide through distress tolerance protocols
- Help users identify and label emotions
- Support interpersonal effectiveness in social situations

### 1.5 Person-Centered/Humanistic Therapy

Core Principles
- The client is the expert on their own life
- Therapist provides unconditional positive regard, empathy, genuineness
- Self-actualization is innate and therapy removes barriers to it

Key Techniques
- Reflective Listening (Deep, accurate understanding of the person's experience)
- Unconditional Positive Regard (Non-judgmental acceptance)
- Empathic Understanding (Seeing the world from the client's perspective)
- Genuineness/Congruence (Authenticity in the therapeutic relationship)

AI Application
- Practice deep, accurate reflection of feelings and content
- Communicate acceptance and non-judgment
- Explore the user's experience
- Trust the user's capacity to find their own answers

### 1.6 Solution-Focused Brief Therapy (SFBT)

Core Principles
- Focus on solutions rather than problems
- Client already has resources