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
8. Phrase the question differently
These techniques are illustrated in the transcripts below.
Heightening the Emotional and Physiological Response
TherapisT: Sally, when you were thinking about volunteering in class, what was just going through your mind?
paTienT: I’m not sure.
TherapisT: How were you feeling?
paTienT: Anxious, I think.
TherapisT: Where did you feel the anxiety?
paTienT: Here (pointing to her abdomen). In the pit of my stomach.
TherapisT: Can you feel the same feeling now?
paTienT: (Nods.)
TherapisT: So you’re sitting in class, thinking about volunteering, and you feel that anxiety in the pit of your stomach . . . What’s going through your mind?
paTienT: If I say something, it won’t come out right. People will judge me.
Eliciting a Detailed Description
TherapisT: So, you were alone in your room last night and you began feeling really upset?
paTienT: Yes.
TherapisT: What was going through your mind?
paTienT: I don’t know. I was just feeling so down, sad.
TherapisT: Can you describe the scene for me? What time was it? Were you alone? What were you doing? What else was going on?
paTienT: It was about 6:15. I had just gotten back from dinner. The dorm was pretty empty because I ate early. I was about to get my books out of my backpack so I could do my Chem homework . . . TherapisT: So you were about to do your homework and you were
thinking . . .
paTienT: [expressing her automatic thoughts] This is just too hard. I’ll never understand it.
TherapisT: And then what happened?
paTienT: I just lay down on my bed.
TherapisT: And as you were lying there, what was going through your mind?
paTienT: I don’t want to do this. I don’t want to be here.
Visualizing the Situation
TherapisT: Sally, can you imagine that you’re back in the class right now, the professor is talking, the student next to you is whispering, you’re feeling nervous . . . Can you visualize it, as if it’s happening right now? How big is the class? Where are you sitting? What is the professor saying? What are you doing? And so on.
paTienT: I’m in my Economics class. The professor is standing in front of the class. Let’s see, [shifting to past tense, which makes the expe- rience less immediate and decreases the emotional response] I was sitting about three-quarters of the way back, I was listening pretty hard . . .
Identifying Automatic Thoughts 145 TherapisT: [guiding the patient to speak as if it’s happening right at
the moment] So, “I’m sitting three-quarters of the way back, I’m listening pretty hard . . .”
paTienT: She’s saying something about what topics we can choose, a macroeconomic view of the economy or . . . something, and then this guy on my left leans over and whispers, “When’s the paper due?”
TherapisT: And what’s going through your mind right now?
paTienT: What did she say? What did I miss? Now I won’t know what to do.
Re-Creating an Interpersonal Situation through Role Play
Patients describe who said what verbally, then patients play themselves while you play the other person in the interaction.
TherapisT: So, you were feeling down as you were talking to your class- mate about the assignment?
paTienT: Yes.
TherapisT: What was going through your mind as you were talking to her?
paTienT: (Pauses.) . . . I don’t know. I was just really down.
TherapisT: Can you tell me what you said to her and what she said to you?
paTienT: (Describes verbal exchange.)
TherapisT: How about if we try a role play? I’ll be the classmate and you be you.
paTienT: Okay.
TherapisT: While we’re recreating the situation, see if you can figure out what’s going through your mind.
paTienT: (Nods.)
TherapisT: Okay, you start. What do you say first?
paTienT: Lisa, can I ask you a question?
TherapisT: Sure, but can you call me later? I’ve got to run to my next class.
paTienT: It’s fast. I just missed part of what Dr. Smith said about our paper.
TherapisT: I’m really in a hurry now. Call me after 7 o’clock, okay?
Bye . . . Okay, out of role play. Were you aware of what was going through your mind?
paTienT: Yeah. I was thinking that she was too busy for me, that she didn’t really want to help me, and I wouldn’t know what to do.
TherapisT: You had the thoughts, “She’s too busy for me,” “She doesn’t really want to help me,” “I won’t know what to do.”
paTienT: Yes.
TherapisT: And those thoughts made you feel sad?
paTienT: Yes.
Eliciting an Image
TherapisT: So, when I asked, “How’s school going?” you felt sad. What was going through your mind?
paTienT: I think I was thinking about my Economics class, getting my paper back.
TherapisT: Did you imagine that? Did you have an image in your mind?
paTienT: Yeah. I pictured a “C” at the top, in red ink.
Suggesting an Opposite Thought
TherapisT: So when you were sitting alone in your room, were you thinking how great everything is going?
paTienT: No, not at all! I was thinking that I don’t know whether I belong here.
Uncovering the Meaning of the Situation
TherapisT: What did it mean to you that you got a B– on your paper?
paTienT: That I’m not smart enough. I don’t have what it takes.
Phrasing the Question Differently
TherapisT: So when your mom didn’t call you back, what were you thinking? Were you making a prediction? Were you remembering something?
It is also possible, though usually less desirable, to ask patients, “What do you guess what you were thinking?” or “Could you have been think- ing about or ?” because patients may spec- ulate inaccurately. Sometimes, however, these two questions are effec- tive.
Identifying Automatic Thoughts 147 You will try one or more of the techniques above when patients have difficulty identifying their automatic thoughts. But if they still experience difficulty, you might collaboratively decide to change the subject, to avoid patients’ feeling that they are being interrogated, or to reduce the possibility of their viewing themselves as a failure:
TherapisT: Well, sometimes these thoughts are hard to catch. No big deal. How about if we move on to .
Identifying Additional Automatic Thoughts
It is important to continue questioning patients even after they report an initial automatic thought. Additional questioning may bring to light other important thoughts.
TherapisT: So when you got the test back, you thought, “I should have done better. I should have studied harder.” What else went through your mind?
paTienT: Everyone else probably did better than I did.
TherapisT: Then what?
paTienT: I was thinking, “I shouldn’t even be here. I’m such a failure.”
You should be aware that patients may, in addition, have other automatic thoughts not about the same situation itself, but about their reaction to that situation. They may perceive their emotion, behavior, or physiological reaction in a negative way.
TherapisT: So you had the thought, “I might embarrass myself,” and you felt anxious? Then what happened?
paTienT: My heart started beating real fast and I thought, “What’s wrong with me?”
TherapisT: And you felt. . . ? paTienT: More anxious.
TherapisT: And then?
paTienT: I thought, “I’ll never feel okay.”
TherapisT: And you felt. . . ? paTienT: Sad and hopeless.
TherapisT: And then. . . ?
paTienT: I felt so bad I thought I wouldn’t be much fun at lunch with Allison so I told her I wasn’t feeling well and just went back to my room.
Note that the patient first had automatic thoughts about a specific situation (volunteering in class). Then she had thoughts about her anxiety and her bodily reaction. In many cases, these secondary emo- tional reactions can be quite distressing, and significantly compound an already upsetting situation. Then Sally made a negative prediction that affected her behavior.
To work most efficiently, it is important to determine at which point patients were most distressed (before, during, or after a given incident), and what their automatic thoughts were at that point. Patients may have had distressing automatic thoughts:
Before
• a situation, in anticipation of what might happen (“What if she yells at me?”),
During
• a situation (“She thinks I’m stupid”), and/or After
• a situation, reflecting on what had happened (“I can’t do anything right; I never should have tried”).
Identifying the Problematic Situation
Sometimes, in addition to being unable to identify automatic thoughts associated with a given emotion, patients have difficulty even identify- ing a particular situation or issue that is most troublesome to them (or which part is the most upsetting). When this happens, you can help them pinpoint the most problematic situation by proposing a number of upsetting problems, asking them to hypothetically eliminate one problem, and determining how much relief the patient feels. Once a specific situation has been identified, the automatic thoughts are more easily uncovered.
TherapisT: [summarizing] So, you’ve been very upset for the past few days and you’re not sure why, and you’re having trouble identifying your thoughts—you just feel upset most of the time. Is that right?
paTienT: Yes. I just don’t know why I’ve been so upset all the time.
TherapisT: What kinds of things have you been thinking about?
paTienT: Well, school for one. And I’m not getting along well with my roommate. And then I tried to get hold of my mother again and I couldn’t reach her, and, I don’t know, just everything.
TherapisT: So, there is a problem with school, with your roommate, with reaching your mom . . . anything else?
Identifying Automatic Thoughts 149 paTienT: Yeah. I haven’t been feeling too well. I’m afraid I might be
getting sick.
TherapisT: Which of these situations bothers you the most—school, roommate, reaching your mom, feeling sick?
paTienT: Oh, I don’t know. I’m worried about all of them.
TherapisT: Let’s jot these four things down. Now let’s say hypotheti- cally we could completely eliminate the feeling sick problem. Let’s say you now feel physically fine, how anxious are you now?
paTienT: About the same.
TherapisT: Okay. Say, hypothetically, you do reach your mom right away after therapy, and everything’s fine with her. How do you feel now?
paTienT: A little bit better. Not that much.
TherapisT: Okay. Let’s say the school problem—what is the school problem?
paTienT: I have a paper due next week.
TherapisT: Okay, let’s say you’ve just handed the paper in early, and you’re feeling good about it. Now how do you feel?
paTienT: That would be a great relief, if that paper were done and I thought I’d done well.
TherapisT: So it sounds as if it’s the paper that is the most distressing situation.
paTienT: Yeah. I think so.
TherapisT: Now, just to make sure . . . If you still had the paper to do, but the roommate problem disappeared, how would you feel?
paTienT: Not that good. I think it is the paper that’s bothering me the most.
TherapisT: In a moment, we’ll focus on the school problem, but first I’d like to review how we figured it out, so you’ll be able to do it yourself in the future.
paTienT: Well, you had me list all the things I was worried about, and pretend to solve them one by one.
TherapisT: And then you were able to see which one would give you the most relief if it had been resolved.
paTienT: Yeah.
We then focus on the school problem, identifying and responding to automatic thoughts and doing some problem solving.
The same process can be used in helping the patient to determine which part of a seemingly overwhelming problem is most distressing.
TherapisT: So you’ve been pretty upset about your roommate. What specifically has been bothering you?
paTienT: Oh, I don’t know. Everything.
TherapisT: Can you name some things?
paTienT: Well, she’s been taking my food and not replacing it. Not in a malicious way, but it still bothers me. And she’s got a boyfriend, and whenever she talks about him, it reminds me that I don’t have one.
And she’s messy; she leaves stuff all around . . . And she’s kind of inconsiderate. Sometimes she talks really loudly on her cell phone.
TherapisT: Anything else?
paTienT: Those are the major things.
TherapisT: Okay, we’ve done this before. Let me read these back to you so you can figure out which one bothers you the most. If you can’t, we’ll hypothetically eliminate them one by one, and see which one makes the biggest difference in how you feel. Okay?
Differentiating between Automatic Thoughts and Interpretations
When you ask for patients’ automatic thoughts, you are seeking the actual words or images that have gone through their mind. Until they have learned to recognize these thoughts, many patients report inter- pretations, which may or may not reflect their actual thoughts. In the following transcript, I guide a patient in reporting her thoughts.
TherapisT: When you saw that woman in the cafeteria, what went through your mind?
paTienT: I think I was denying my real feelings.
TherapisT: What were you actually thinking?
paTienT: I’m not sure what you mean.
In this exchange, the patient reported an interpretation of what she was feeling and thinking. Below, I try again, by focusing on and heighten- ing her emotion.
TherapisT: When you saw her, what emotion did you feel?
paTienT: I think I was just denying my feelings.
TherapisT: Uh-huh. What feelings were you denying?
Identifying Automatic Thoughts 151 paTienT: I’m not sure.
TherapisT: [supplying an emotion opposite to the expected one to jog her recall] When you saw her, did you feel happy? Excited?
paTienT: No, not at all.
TherapisT: Can you remember walking into the cafeteria and seeing her? Can you picture that in your mind?
paTienT: Uh-huh.
TherapisT: What are you feeling?
paTienT: Sad, I think.
TherapisT: As you look at her, what goes through your mind?
paTienT: [reporting an emotion and a physiological reaction, instead of an automatic thought] I feel really sad, an emptiness in the pit of my stomach.
TherapisT: What’s going through your mind now?
paTienT: She’s really smart. [automatic thought] I’m nothing com- pared to her.
TherapisT: Okay. Anything else?
paTienT: No. I just walked over to the table and started talking to my friend.
Specifying Automatic Thoughts Embedded in Discourse
Patients need to learn to specify the actual words that go through their minds in order to evaluate them effectively. Following are some exam- ples of embedded thoughts versus actual words:
Embedded expressions Actual automatic thoughts I guess I was wondering if he likes me. Does he like me?
I don’t know if going to the professor would be a waste of time.
It’ll probably be a waste of time if I go.
I couldn’t get myself to start reading. I can’t do this.
You gently lead patients to identify the actual words that went through their mind.
TherapisT: So when you turned bright red in class, what went through your mind?
paTienT: I guess I was wondering if he thought I was strange.
TherapisT: Can you recall the exact words you were thinking?
paTienT: (puzzled) I’m not sure what you mean.
TherapisT: Were you thinking, “I guess I was wondering if he thought I was strange,” or were you thinking, “Does he think I’m strange?”
paTienT: Oh, I see, the second one. Or actually I think it was, “He prob- ably thinks I’m strange.”
Changing the Form of Telegraphic or Question Thoughts
Patients often report thoughts that are not fully spelled out. As it is dif- ficult to evaluate such a telegraphic thought, you guide the patient to express the thought more fully.
TherapisT: What went through your mind when the paper was announced?
paTienT: “Uh-oh.” I just thought, “Uh-oh.”
TherapisT: Can you spell the thought out? “Uh-oh” means . . . paTienT: I’ll never get the work done in time. I have too much to do.
If patients are unable to spell out their thought, you might try supplying an opposite thought: “Did ‘Uh-oh’ mean, ‘That’s really good’?”
Automatic thoughts are sometimes expressed in the form of a question, making evaluation difficult. Therefore, you guide patients in expressing their thoughts in a statement form prior to helping them evaluate it.
TherapisT: So you felt anxious? What was going through your mind right then?
paTienT: I was thinking, “Will I pass the test?”
TherapisT: Okay. Were you thinking you probably would or wouldn’t pass the test?
paTienT: That I wouldn’t.
TherapisT: Okay. So can we rephrase your thought as, “I might not pass the test”?
Another example follows:
TherapisT: So you had the thought, “What will happen to me [if I get more and more nervous]?” What are you afraid could happen?
paTienT: I don’t know . . . lose control, I guess.
Identifying Automatic Thoughts 153
TherapisT: Okay, let’s look at that thought, “I could lose control.”
Here I lead the patient into revealing precisely what she fears. In the next example, the patient initially has difficulty identifying the fear behind her automatic thought. I try several different questions.
TherapisT: So you thought, “What next?” What did you think would happen next?
paTienT: I don’t know.
TherapisT: Were you afraid something specific might happen?
paTienT: I’m not sure.
TherapisT: What’s the worst thing that could happen in this situation?
paTienT: Ummm . . . that I’d get kicked out of school.
TherapisT: Do you think that was what you were afraid would hap- pen?
Other examples of how questions can be restated in order to be evaluated more effectively are presented below:
Question Statement
“Will I be able to cope?” “I won’t be able to cope.”
“Can I stand it if she leaves?” “I won’t be able to stand it if she leaves.”
“What if I can’t do it?” “I’ll lose my job if I can’t do it.”
“What if she gets mad at me?” “She’ll hurt me if she gets mad at me.”
“How will I get through it?” “I won’t be able to get through it.”
“What if I can’t change?” “I’ll be miserable forever if I can’t change.”
“Why did this happen to me?” “This shouldn’t have happened to me.”
Recognizing Situations That Can Evoke Automatic Thoughts Up to this point, most of the examples of automatic thoughts provided in this chapter have been associated with external events (e.g., talking to a friend) or a stream of thoughts (e.g., thinking about an upcoming exam). But a wide range of both external stimuli and internal experi- ences can give rise to automatic thoughts. As illustrated in Figure 9.1,
Situation (external event, stream of thoughts, or internal experiences)
Initial Automatic Thoughts
Emotion
Behavior
Physiological Reaction
Potential Additional Automatic Thoughts
Emotion
Behavior
Physiological Reaction
FIGURE 9.2. Initial and secondary thoughts and reactions.
Situation/Stimulus Example Automatic Thoughts External event (or
series of events)
mother keeps hanging up the phone.
“How dare she treat me like this!”
Stream of thoughts Thinking about the exam “I’ll never learn this stuff.”
Cognition: thought, image, belief, daydream, dream, memory, flashback
Becomes aware of a violent image.
“I must be crazy.”
Has a flashback of a traumatic event
“I’ll never get over this.
I’ll always be plagued by these terrible flashbacks.”
Emotion Anger “I shouldn’t be angry
at him. I’m such a bad person.”
Behavior Binge eats “I’m so weak. I just can’t get my eating under control.”
Physiological or mental experience
Rapid heartbeat “What if there’s something seriously wrong with me?”
Sense of unreality “I must be going crazy.”
FIGURE 9.1. Situations that evoke automatic thoughts.