Work the Agenda
In CBT you are going to spend a lot of time and effort helping your clients identify and examine their thoughts. You want to be sure that time is well spent. We all have a continual stream of thoughts that go through our head every day, and not every thought is worth working on. You want to target thoughts that are central to your client’s distress and which, when targeted, will lead to meaningful change.
Agenda Item #1: Identify Hot Thoughts
Thoughts that are worth working on explain the meaning of the situation and are strongly con- nected to intense feelings. We call these hot thoughts (Safran, Vallis, Segal, & Shaw, 1986) because they carry emotion, and when we work with them in therapy there is meaningful change.
Here is an example. Jaylen’s father lives six hours away. He calls Jaylen once a week and always starts the conversation by sighing and saying, “I never see you. When will you come visit? I miss you.”
Every week his father’s phone call triggers the same negative automatic thoughts: My father has called every week for the past two years. He is always critical. He does not appreciate what I do for him. Let’s look at Jaylen’s thoughts and identify which ones are hot thoughts. The thought My father has called every week for the past two years is a fact; it does not explain what his father’s phone call means to Jaylen or the reason for Jaylen’s emotional distress. It is not a hot thought. The thoughts He is always critical and He does not appreciate what I do for him are hot thoughts because they capture what his father’s words mean to him and explain Jaylen’s emotional reaction.
When you are first learning CBT, it can be hard to know which thoughts are hot thoughts and worth focusing on. In this chapter we are going to look at three guidelines to help you identify a hot thought. Remember, a hot thought has to capture the meaning of the situation and is related to intense feelings. Below are the three guidelines.
1. Is this thought an unrealistic evaluation of self, others, or the future?
2. Does this thought explain your client’s feelings?
3. Does this thought contain a cognitive distortion?
Agenda Item #2: Is This Thought an Unrealistic Evaluation of Self, Others, or the Future?
It is your client’s unrealistic thoughts about self, others, or the future that capture the meaning of a situation and help you understand her distress.
Sometimes it is easier to understand a concept if we start with an example. A client of mine, Regina, was recently fired from a job and was feeling very depressed and anxious. When I asked what she was thinking, she responded, “I can’t believe I was fired” and “I wish I hadn’t been fired.” These thoughts do not explain what being fired means to Regina, so they are not hot thoughts. I asked addi- tional questions and we identified the following thoughts:
Evaluation of self (thoughts that are a judgment about yourself)
• I am too old to learn another skill.
• Something is wrong with me.
• I am stupid.
Try to think of a negative evaluation that you have of yourself, or that one of your clients has of herself.
Evaluation of others (thoughts that are a judgment about other people or an expectation about how other people will treat you)
• My boss is unfair.
• My father will be disappointed.
• None of my colleagues cares about me.
Try to think of a negative evaluation that you have of other people, or that one of your clients has of others.
Evaluation of the future (thoughts that are a judgment of the future or an expectation of what the future will be like)
• My friends and partner will no longer respect me (this is both about others and the future).
• I will be poor and lose my house.
• I will never get another job that is as good.
Try to think of a negative evaluation that you have of the future, or that one of your clients has of the future.
When you look at the thoughts that Regina identified about self, others, and the future, can you see how they explain what getting fired meant to Regina and why these thoughts would lead to her feeling depressed and anxious?
Let’s look more closely at how to identify thoughts about self, as they can sometimes be hard to identify. Some thoughts are clearly about the self, for example, I made a serious mistake, or I am disorga- nized. However, sometimes negative thoughts about self are hidden in thoughts about others and in particular thoughts about how others treat you. Let’s take the thought My colleague never asks my opinion. You could believe this is the case because your colleague is unpleasant and bossy (thought about others), but you believe that you have good ideas (thought about self). In this case, the negative judgment is about your colleague and there are no negative judgments about yourself. However, you could believe that your colleague never asks your opinion because she thinks you do not have good ideas, and you think this as well. In this case, you have a negative judgment about your colleague, but you also have a negative judgment about yourself.
Here are some more examples of thoughts about others where there may be hidden negative beliefs about self: None of my new colleagues would want to be my friend, No one would want to help me, and No one will ever want to stay married to me. In all these situations, your client may believe that there is something about her that causes the other person’s negative behavior. For example, a client might think, None of my new colleagues would want to be my friend because I am too shy and boring. “I am too shy and boring” is a negative thought about self. A client could also think none of her new colleagues wants to be her friend because they are all close to retirement and are not interested in making new friends at work. In this case, there is no underlying negative evaluation of self. You can check whether there is an underlying negative evaluation of self by asking your client, “Is there something about you that would cause the other person to treat you this way?”
Your Turn!
Identify Suzanne’s Thoughts about Self, Others, and the Future
In their fourth session, Suzanne wanted to talk about how upset she was with her husband. She describes a recent fight. A few nights ago her husband was watching TV when she asked him if he had bathed Andrew, their four-year-old son. He responded by saying, “I’m exhausted, can you do it?” Suzanne blew up at him, yelled that he had promised to give their son a bath and that he was selfish, and then stomped out of the room. She is feeling depressed and hopeless. Her therapist wants to understand the thoughts that caused her to become so upset. Another way of thinking about it is, what did it mean to Suzanne that her husband did not give Andrew a bath and said, “Can you do it?”
Look over the dialogue and list Suzanne’s thoughts. Then decide if the thought is a fact or an evaluation of self, others, or the future. You can find my answers in the appendix.
Therapist: What were you thinking when you realized your husband did not give Andrew his bath and said, “I’m exhausted, can you do it?”
Suzanne: I just keep thinking that he didn’t give Andrew his bath; no matter what I do, it won’t make a difference.
Therapist: Any other thoughts?
Suzanne: He doesn’t care about the kids or me. Besides, you can’t count on men.
Therapist: Can you tell me more about those thoughts?
Suzanne: I keep thinking that I’m a completely inadequate mother; I keep asking myself, Why do I have to do everything in the house?
Therapist: A lot of thoughts, any others?
Suzanne: No, that’s probably all; it’s enough!
Exercise 6.1: (a) Jim Forgets His Wallet, and (b) Richard’s Boyfriend Wants to End the Relationship
Practice identifying thoughts about self, others, or the future.
Agenda Item #3 : Does This Thought Explain Your Client’s Feelings?
The second guideline for evaluating whether your client has identified her hot thoughts is examin- ing whether her thoughts explain her feelings, and in particular her strong negative feelings. What do I mean by this? Given your client’s thoughts, the feelings have to make sense, and the intensity of the feeling has to make sense. Let’s look at an example.
A client of mine, Angela, was concerned about her new babysitting arrangements. When her therapist asks about the situation, Angela explains that when she left her daughter with the new baby- sitter, her daughter cried and begged Angela not to leave. This is unusual behavior for her daughter, who loved her previous sitter and usually played happily when Angela left her with the sitter in the morning. Angela is feeling very guilty (8) and anxious (8–9). When asked about her thoughts, Angela responded, “My daughter is probably upset because it is a new sitter. She will just have to get used to her. It will take time.”
These are very good coping thoughts; however, they don’t help us understand Angela’s feelings. If she really believed these thoughts, and she had no others, would she feel guilty at 8 and anxious at 8 to 9? Probably not. Given the strength of her anxiety and guilt, there are probably some other thoughts that Angela is not aware of. Had Angela’s feelings been “slightly sad,” these thoughts would have made sense.
When your client’s thoughts don’t match her feelings, this is a sign that you need to keep exploring to identify the underlying thoughts. We will get to how you can help your clients identify their underly- ing thoughts in the next chapter.
Different feelings have different types of accompanying thoughts. In CBT we call this content speci- ficity (Beck et al., 1979). Let’s look at the kind of thoughts that go with anxiety, depression, anger, guilt, and shame. Take a moment and think of the last time that you were anxious, and then focus on the feeling. What thoughts accompany this feeling of anxiety? Jot down your thoughts. Now do the same for depression, anger, guilt, and shame. See whether your own thoughts fit with the descriptions below.