COGNITIVE BEHAVIOR THERAPY
SESSION 3 AND BEYOND
A: You obviously would not ask the “How would you cope?” question
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?
Evaluating Automatic Thoughts 175 TherapisT: And what could be the effect of changing your thinking?
paTienT: I’d feel better.
The “Distancing” Questions
Patients often benefit from getting some distance from their thoughts by imagining what they would tell a close friend or family member in a similar situation.
TherapisT: Sally, let’s say your friend Allison had a friend who some- times was rushed, but seemed caring at other times. If Allison had the thought, “My friend doesn’t care about me,” what would you tell her?
paTienT: I guess I’d tell her not to put too much importance on the times she seemed rushed, especially if her friend was nice about it.
TherapisT: Does that apply to you?
paTienT: Yes, I guess it does.
The “Problem-Solving” Questions
The answer to this question may be cognitive and/or behavioral in nature. The cognitive part would entail having patients remember their responses to the questions. In Sally’s case, we came up with a behavioral plan:
TherapisT: And what do you think you should do about this situation?
paTienT: Uh . . . I’m not sure what you mean.
TherapisT: Well, have you withdrawn any since this happened yester- day?
paTienT: Yeah, I think so. I didn’t say much when I saw her this morn- ing.
TherapisT: So this morning you were still acting as if that original thought were true. How could you act differently?
paTienT: I could talk to her more, be friendlier myself.
If I were unsure of Sally’s social skills or motivation to carry through with this plan of being friendlier to Karen, I might have spent a few min- utes asking Sally such questions as “When might you see her again?”;
“Would it be worth it, do you think, to seek her out yourself?”; “What could you say to her when you do see her?”; “Anything you think could get in the way of your saying that?” (If needed, I might have modeled what she could say to Karen, and/or engaged Sally in a role play.)
ASSESSING THE OUTCOmE Of THE EVAlUATION PROCESS
In the last part of this discussion, I assess how much Sally now believes the original automatic thought and how she feels emotionally, so I can decide what to do next in the session.
TherapisT: Good. Now, how much do you believe this thought: “Karen doesn’t really care what happens to me”?
paTienT: Not very much. Maybe 20%.
TherapisT: Okay. And how sad do you feel?
paTienT: Not much either.
TherapisT: Good. It sounds like this exercise was useful. Let’s go back and see what we did that helped.
You and the patient will not use all the questions in Figure 11.1 for every automatic thought you evaluate. Sometimes none of the questions seems useful, and you might take another tack altogether (see pages 178–186).
CONCEPTUAlIzING WHY THE EVAlUATION Of AN AUTOmATIC THOUGHT WAS INEffECTIVE If the patient still believes the automatic thought to a significant degree and does not feel better emotionally, you need to conceptualize why this initial attempt at cognitive restructuring has not been sufficiently effective. Common reasons to consider include the following:
1. There are other, more central automatic thoughts and/
or images left unidentified or unevaluated.
2. The evaluation of the automatic thought is implausible, superficial, or inadequate.
3. The patient has not sufficiently expressed the evidence that he or she believes supports the automatic thought.
4. The automatic thought itself is also a core belief.
5. The patient understands intellectually that the automatic thought is distorted, but does not believe it on an emotional level.
Evaluating Automatic Thoughts 177 In the first situation, the patient has not verbalized the most central automatic thought or image. John, for example, reports the thought, “If I try out [for the community basketball team], I probably won’t make it.” Evaluating this thought does not significantly affect his dysphoria because he has other important (but unrecognized) thoughts: “What if they think I’m a lousy player?” “What if I make stupid mistakes?” He also has an image of the coach and other players watching him with mocking, scornful faces.
In a second situation, the patient responds to an automatic thought super- ficially. John thinks, “I won’t finish all my work. I have too much to do.”
Instead of carefully evaluating the thought, John merely responds, “No, I’ll probably get it done.” This response is insufficient, and his anxiety does not decrease.
In a third situation, the therapist does not thoroughly probe for, and there- fore the patient does not fully express the evidence that his or her automatic thought is true, resulting in an ineffective adaptive response, as seen here:
TherapisT: Okay, John, what evidence do you have that your sister doesn’t want to bother with you?
paTienT: Well, she hardly ever calls me. I always call her.
TherapisT: Okay, anything on the other side? That she does care about you, that she does want a good relationship with you?
Had John’s therapist queried him further, he would have uncov- ered other evidence that John has to support his automatic thought:
that his sister spent more time with her girlfriends during vacations than with John, that she sounded impatient on the phone when he called, and that she had not sent him a birthday card. Having elicited this additional data, the therapist could have helped John weigh the evidence more effectively and investigated alternative explanations for his sister’s behavior.
In a fourth situation, the patient identifies an automatic thought that is also a core belief. John often thinks, “I’m incompetent.” He believes this idea so strongly that a single evaluation does not alter his perception or the associated affect. His therapist needs to use many techniques over time to alter this belief (see Chapter 14).
In a fifth situation, the patient indicates that he believes an adaptive response “intellectually,” in his mind, but not “emotionally,” in his heart, soul, or gut. He discounts the adaptive response. In this case, the therapist and patient need to explore an unarticulated belief that lies behind the automatic thought: