Did you have a chance to do the homework from the last chapter? Here is one of my catastrophizing cognitive distortions that I caught. I am in the car, driving to a meeting with colleagues I don’t know very well. I pick up coffee, and within five minutes I manage to spill a good part of it on my new white shirt. Can you guess my thoughts? I will look like a complete idiot; everyone will think I am totally incom- petent. However, the truth is I simply pulled my jacket over my shirt—and it wasn’t great, but it certainly wasn’t a catastrophe. Were you able to catch any of your own cognitive distortions? Were you able to identify your clients’ thoughts about self, others, or the future?
If you did the homework, take a moment to reflect on what you learned. If you did not do the homework, think about an upsetting experience that happened last week. Identify your thoughts and then ask yourself, Do my thoughts contain unrealistic judgments about self, others, or the future? Are they a cognitive distortion?
Set the Agenda
In the last chapter we focused on how to decide which thoughts are worth working on. Now that we know what to look for, it’s time to get our hands dirty and learn how to look.
Agenda Item #1: Identify automatic thoughts.
Agenda Item #2: Helpful questions.
Agenda Item #3: Your clients’ images.
Agenda Item #4: Additional strategies to identify thoughts.
Agenda Item #5: How do you know which questions to use?
Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior.
Work the Agenda
Remember that the purpose of identifying your client’s thoughts is to understand what a situation means to your client, or how he interpreted the situation. We want to help our clients identify their hot thoughts. To recap, a hot thought explains your client’s feelings and behavior and is an unrealistically negative evaluation of self, others, or the future.
Clients can have a variety of reactions when they start to identify their negative thoughts. Many clients feel more in control when they understand what is maintaining their difficulties and can iden- tify the relationship between their thoughts, feelings, physical reactions, and behaviors. Other clients become more distressed when they realize how negative their thoughts really are. It is important to explain that even though it can be hard to look at negative thoughts, it is a first step to feeling better.
Agenda Item #1: Identify Automatic Thoughts
It sounds simple, but if you want to know what your client is thinking, just ask. The following “Just Ask” questions are often all that you need.
“Just Ask” Questions
General Probing Questions • What were you thinking?• What were you saying to yourself at the time?
• What was running through your mind?
Prompting Questions • Any other thoughts?
• Anything else?
Reflective Statements • So you were thinking…(repeat last thought)
Often just repeating the last thought or statement will encourage the client to elaborate on more thoughts. You can then choose to add a prompting question.
Clarifying Questions • Can you tell me more about that thought?
When you ask your client, “What were you thinking?” use a gentle, curious tone that encourages self-reflection. It is often helpful to refer to the situation you are exploring. For example, Suzanne’s therapist asked, “When you received the invitation to the barbecue, what were your thoughts?” Don’t forget to go slowly and give your client time. It can take a couple of questions before your client can identify his thoughts.
Let’s look at the example we started working on with Suzanne in chapter 5. If you remember, the principal of her new school invited her to a barbecue with the other new teachers. You know about the
situation (invitation to the barbecue), you already know her feelings (nervous, worried, and embar- rassed), you know her physical reaction (clenched stomach and tense shoulders), and you know her behavior (put the invitation aside and did not respond). You now want to identify Suzanne’s thoughts, and in particular you want to help her identify her hot thoughts. Let’s see what happens if her therapist uses the “Just Ask” questions.
Therapist: Suzanne, you have done a good job identifying your feelings, physical reactions, and behav- ior. Let’s see if we can also identify your thoughts. When you were invited to the party, what thoughts went through your mind?
Notice her therapist starts by positively reinforcing Suzanne for identifying her feelings, physical reactions, and behavior. She then refers to the situation before asking a general probing question.
Suzanne: (pausing) I don’t know, just that I don’t want to go; the other new teachers will all be there.
The thought I don’t want to go is the behavior Suzanne wants to do. It is a fact. The thought All the
other new teachers will be there is also a fact. These thoughts do not contain unrealistic judgmentsabout self, others, or the future; they do not explain her feelings; and they do not contain a cognitive distor- tion. Suzanne has not yet identified a hot thought.
Therapist: Any other thoughts?
The therapist uses a prompting question.
Suzanne: Well, just that I won’t fit in.
Suzanne is starting to identify her hot thoughts. I won’t fit in is a thought about self. Her therapist wants to keep exploring.
Therapist: Are there other thoughts that go with I won’t fit in?
The therapist uses another prompting question.
Suzanne: I feel that I will just stand there looking awkward, and no one will talk to me. I will be so anxious, and I will probably get all sweaty.
This is an example of a client using “I feel,” when what Suzanne really means is “I think.” When this happens, simply repeat the sentence saying, “You were thinking,…”
Therapist: You were thinking, I will just stand there looking awkward, no one will talk to me, and I will probably get all sweaty.
Suzanne: That’s right, it’s not just that they won’t talk to me, it’s that no one will want to talk to me.
At this point Suzanne has identified a thought about herself: I won’t fit in; thoughts about herself and the future: I will stand there looking awkward, and I will probably get all sweaty; and a thought about others and the future: no one will want to talk to me.
Her therapist then asked Suzanne if she would like to write down her thoughts on the Understand Your Reaction worksheet. Sometimes clients like to write, and sometimes they like me to write. I don’t
think it matters. If I am writing, I repeat my client’s thoughts out loud as I write. I find that this encour- ages my client to start thinking about his thoughts, rather than just experiencing them.
Let’s see what Suzanne’s worksheet looks like.
Understand Your Reaction
Situation Feelings(Rate 1–10)
Physical Reactions (Rate 1–10)
Behaviors Thoughts
What? Who?
Where? When? What did I feel? How did my
body react? What did I do? What did I think?
Principal invited me to barbecue with the three other new teachers
Nervous (7) Worried (8) Embarrassed (6)
Clenched stomach (4) Tense shoulders (5)
Has not
responded • I don’t want to go.
• The other new teachers will be there.
• I won’t fit in.
• I will just stand there looking awkward.
• No one will want to talk to me.
• I will probably get all sweaty.
Agenda Item #2: Helpful Questions
Sometimes when you ask your clients what they are thinking, they respond with thoughts that are not hot thoughts. For example, Raoul felt very awkward going to the lunchroom. When his therapist asked what he was thinking, he responded, “I don’t know, I just feel awkward.” His therapist needs to ask additional questions to help Raoul identify his thoughts.