COGNITIVE BEHAVIOR THERAPY
SESSION 3 AND BEYOND
A: If they do not spontaneously tell you that your interruptions were distressing, ask them what was just going through their minds
3. Challenging a cognition violates a fundamental principal of cognitive behavior therapy, that of collaborative empiricism: You
and the patient together examine the automatic thought, test its validity and/or utility, and develop a more adaptive response.
It is also important to keep in mind that automatic thoughts are rarely completely erroneous. Usually, they contain at least a grain of truth (which is important that you acknowledge).
Figure 11.1 contains a list of Socratic questions to help patients evaluate their thinking. (Actually, “Socratic” is a misnomer some of the time; the Socratic questioning method, derived from the philosopher Socrates, involves a dialectical discussion.) Patients need a structured method to evaluate their thinking; otherwise, their responses to auto- matic thoughts can be superficial and unconvincing and will fail to improve their mood or functioning. The evaluation should be even- handed. You do not want patients, for example, to ignore evidence that
Evaluating Automatic Thoughts 171 supports an automatic thought, devise an alternative explanation that is not likely, or adopt an unrealistically positive view of what might hap- pen.It is important to relate to patients that not all of the questions in Figure 11.1 are suitable for every automatic thought. Moreover, using all of the questions, even if they logically apply, may be too cumbersome and time consuming. Patients may not evaluate their thoughts at all if they consider the process too burdensome. Usually you will introduce just one or a few questions at a time.
You may use questioning from the very first session to evaluate a specific automatic thought. In a subsequent session, you will begin to explain the process more explicitly, so patients can learn to evaluate their thinking between sessions:
TherapisT: (Summarizes past portion of the session; writes automatic thoughts on paper for both to see) So when you met your friend Karen on the way to the class, you had the thought, “She doesn’t really care what happens to me,” and that thought made you feel sad?
paTienT: Yeah.
TherapisT: And how much did you believe that thought at the time?
paTienT: Oh, pretty much. About 90%.
TherapisT: And how sad did you feel?
paTienT: Maybe 80%.
TherapisT: Do you remember what we said last week? Sometimes automatic thoughts are true, sometimes they turn out not to be true, and sometimes they have a grain of truth. Can we look at this thought about Karen now, and see how accurate it seems?
paTienT: Okay.
You can use any set of questions to help patients evaluate their thinking, but Figure 11.1 can be helpful as it guides you and the patient to:
Examine the validity of the automatic thought.
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Explore the possibility of other interpretations or viewpoints.
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Decatastrophize the problematic situation.
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Recognize the impact of believing the automatic thought.
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Gain distance from the thought.
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Take steps to solve the problem.
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Each of the questions is described below.
The “Evidence” Questions
Because automatic thoughts usually contain a grain of truth, patients usually do have some evidence that supports their accuracy (which you will seek first), but they often fail to recognize evidence to the contrary (which you will seek second):
TherapisT: What’s the evidence that Karen doesn’t care what happens to you?
paTienT: Well, when we passed on Locust Walk, she seemed like she was real rushed. She just quickly said, “Hi, Sally, see you later,” and kept going fast. She hardly even looked at me.
TherapisT: Anything else?
paTienT: Well, sometimes she’s pretty busy and doesn’t have much time for me.
TherapisT: Anything else?
paTienT: (Thinks.) No. I guess not.
TherapisT: Okay, now is there any evidence on the other side, that maybe she does care about what happens to you?
1. What is the evidence that supports this idea?
What is the evidence against this idea?
2. Is there an alternative explanation or viewpoint?
3. What is the worst that could happen (if I’m not already thinking the worst)?
If it happened, how could I cope?
What is the best that could happen?
What is the most realistic outcome?
4. What is the effect of my believing the automatic thought?
What could be the effect of changing my thinking?
5. What would I tell [a specific friend or family member]
if he or she were in the same situation?
6. What should I do?
FIGURE 11.1. Questioning automatic thoughts.
Evaluating Automatic Thoughts 173 paTienT: (answering in general terms) Well, she is pretty nice. We’ve been
friends since school started.
TherapisT: [helping Sally think more specifically] What kinds of things does she do or say that might show she likes you?
paTienT: Ummm . . . she usually asks if I want to go get something to eat with her. Sometimes we stay up pretty late just talking about things.
TherapisT: Okay. So, on the one hand, on this occasion yesterday, she rushed by you, not saying much. And there have been other times, too, when she’s been pretty busy. But on the other hand, she asks you to eat with her, and you stay up late talking sometimes. Right?
paTienT: Yeah.
Here I gently probed to uncover evidence regarding the validity of Sally’s thought. Having elicited evidence on both sides, I summarized what Sally said.
The “Alternative Explanation” Questions
Below, I help Sally devise a reasonable alternative explanation for what has happened.
TherapisT: Good. Now, let’s look at the situation again. Could there be an alternative explanation for what happened, other than she doesn’t care about what happens to you?
paTienT: I don’t know.
TherapisT: Why else might she have rushed by quickly?
paTienT: I’m not sure. She might have had a class. She might have been late for something.
The “Decatastrophizing” Questions
Many patients predict a worst-case scenario. If a patient’s automatic thought does not contain a catastrophe, it is often useful to ask the patients about their worst fear. In both cases, you should follow up by asking patients what they can do if the worst does happen.
TherapisT: Okay. Now, what would be the worst that could happen in this situation?
paTienT: That she would truly not like me, I guess. That I couldn’t count on her for support.
TherapisT: How could you cope with that?
paTienT: Well, I wouldn’t be happy about it. I guess I’d have to stop counting on her friendship.
TherapisT: [asking leading questions to help her develop a robust response] Do you have other friends you could count on?
paTienT: Yes.
TherapisT: So you’d be okay?
paTienT: Yes, I would.
Patients’ worst fears are often unrealistic. Your objective is to help them think of more realistic outcomes, but many patients have diffi- culty doing so. You might help them extend their thinking by first ask- ing for the best outcome.
TherapisT: Now the worst may be unlikely to happen. What’s the best that could happen?
paTienT: That she’ll realize she cut me off. That she’ll apologize.
TherapisT: And what’s the most realistic outcome?
paTienT: That she really was busy and we’ll continue to be friends.
In the previous section, I help Sally see that even if the worst happened, she would cope. She also realizes that her worst fears are unlikely to come true.
Q: What if . . . patients’ worst fears are that they will die?