When clients talk about a difficult situation, they often become emotional. A shift in your client’s mood usually goes with an important thought about self, others, or the future. For example, if a client looks sad, blushes, or becomes agitated, it is an opportunity to “catch” important thoughts. I usually say,
“I noticed you looked sad [or I noticed you looked upset]; what were you thinking?”
Let’s look at an example that Suzanne brought up in the sixth session. Suzanne came into the session saying she wanted to talk about her relationship with her husband. She started in a very calm manner, saying that last night, she said she was tired and wanted to go to bed early. Her husband became annoyed and angry and told her that she was always tired and never wanted to do anything fun anymore. Suzanne started to become teary as she described her husband’s response. Her therapist wanted to identify what thoughts went with her change in mood.
Therapist: You looked teary as you remembered what your husband said.
Suzanne: Yes, it was pretty awful to hear him say that I never want to go out anymore.
Therapist: I am wondering what was going through your mind just now, as you got teary.
Suzanne: (looking very sad and more teary) I thought that if I don’t start being more fun, that he will leave me, and I will be all alone.
YOUR TURN!
Notice Raoul’s Change in Mood
Up to now Raoul has mainly focused on work issues. In session 7 he comes in and tells his therapist that his youngest niece may have a serious illness. He explains in a calm voice, “When I think of the pos- sibility of my niece being sick, I know the whole family will just have to find a way to cope, as hard as it will be.” He then goes on:
Raoul: We will know for sure whether my niece has the illness on Monday, when we get the results of the lab tests. (His voice cracks, he takes a deep breath, and looks very upset.)
How could his therapist use the shift in Raoul’s mood to help him identify his thoughts about the lab results?
Look at the three possible responses below and pick the one that will help Raoul identify his thoughts:
1. What a hard situation. I hope that you are taking care of yourself.
2. You just looked so upset, I am wondering what was going through your mind when you thought of getting the lab results?
3. I can see how upset you are, but I also hear how important it is to you to cope. How are you coping?
Response #2 is the most likely to lead Raoul to identify the thoughts that accompany his change in mood. In response #1, the therapist tries to be supportive but does not ask about Raoul’s thoughts and is giving advice that Raoul did not ask for. In response #3, the therapist tries to be empathic and then moves to problem solving without having a good definition of the problem.
Agenda Item #5: How Do You Know Which Questions to Use?
It can be hard to know which question to use, and there is no right answer. Here is a summary of the questions I use, in the general order in which I use them. You may initially find it helpful to keep this list by your side during therapy. (You can download a Questions to Identify Your Client’s Thoughts handout at http://www.newharbinger.com/38501.) The more you use these questions, the more they will start to feel natural.
• What were you thinking? Any other thoughts?
• When a client’s mood shifts, ask about thoughts.
• What does the situation mean to you? OR What does the situation mean about yourself, others, or your future?
• How is this situation a problem for you?
• What are some of the thoughts that go with your feelings?
• Let’s make a list of your worries. Do you have a worst-case scenario?
• Do you have any images?
• If the thought is a question: How do you answer this question in your mind?
• If the thought is a hope: What are you worried about?
Let’s use some of these questions to help Michael, a twenty-eight-year-old client of mine, to identify his thoughts. Michael’s main agenda was addressing his anxiety about his relationship with a new girl- friend. He didn’t understand why he was so anxious. We began with identifying situations where he felt anxious. Michael told me that his girlfriend was rarely verbally affectionate toward him; she almost never said she missed him or that she was happy to see him. He described a text message he just received where she said, “See you tonight for dinner.” As he talked about her behavior, he became almost teary. Below is how I explored his thoughts; however, there are many other possible helpful responses. As you read through the dialogue, consider what you would have said.
Therapist: When you received the text, what were your thoughts at the time?
Michael: I don’t know, it just doesn’t feel good to get a text like that (eyes well up with tears).
I started with using one of the “Just Ask” questions. However, Michael responded with a thought that was not a hot thought, so I wanted to try another approach.
Therapist: I can see you’re becoming almost teary. What thoughts are going through your mind?
I noticed the shift in his mood and thought it probably signaled an important thought.
Michael: I know she had a relationship with another man for two years before me. I keep wondering, Did she treat him the same way?
Michael’s first thought is a fact: She had a relationship for two years before me. His second thought is a question: Did she treat him the same way? I chose to explore how he answered the question, as there seemed to be more emotion attached to that thought.
Therapist: And how do you answer the question, “Did she treat her past boyfriend in the same way”?
Michael: I think she treated him differently, or the relationship wouldn’t have lasted.
I wanted to explore what it meant to Michael that he thought his girlfriend had treated her previous boy- friend differently.
Therapist: If she did treat her previous boyfriend differently, what would it mean to you?
Michael: That she doesn’t care about me as much as her previous boyfriend, maybe that she doesn’t really care about me at all.
At this point, Michael started to talk with more emotion about his fears that his girlfriend was not com- mitted to the relationship and that he was not very important to her.
Agenda Item #6: Link Thoughts to Feelings, Physical Reactions, and Behavior
At this point in therapy, you have identified a specific situation that is problematic for your client, and you’ve explored your client’s reaction using the four-factor model. Identifying the relationships among the four factors provides your client with a structure for understanding what is maintaining his problems, and provides you with a way of organizing your client’s treatment. Here’s where the written worksheet Understand Your Reaction comes in handy: you and your client have a document you can look at when developing a model to understand the factors that are maintaining his problem.
I start with asking my client to look over the Understand Your Reaction worksheet and ask if he sees a connection among the four factors. Often a client will spontaneously comment that his reaction makes more sense, or that given his thoughts, it makes sense how he is feeling or behaving. If a client does not see the link between his thoughts and his feelings, physical reactions, and behaviors, I point it out to him. For example, I might say, “When I look at your thoughts, it makes sense to me that you
would be [a feeling, for example depressed], or do [a behavior, for example procrastinate]. Does this make sense to you?” If my client agrees with me, I ask him to explain the link among the four factors in his own words.
Let’s look at the Understand Your Reaction worksheet that Suzanne completed to see how we can help her understand her difficulties.
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.
Therapist: Let’s look at what you wrote down. (Suzanne and her therapist look at the worksheet.) When you look at it, do you notice any connection among the four factors?
Suzanne: Sort of…I wasn’t aware that I had all of those thoughts.
Suzanne’s therapist wants to positively reinforce Suzanne for identifying her thoughts. Rather than telling her, she wants Suzanne to make the link between her thoughts and how she was feeling and behaving.
Therapist: You did a really good job of identifying your thoughts. Do you see a connection between your thoughts and your feelings, physical reactions, and behaviors?
Suzanne: I do. It makes sense to me that if all these thoughts were going through my head, I would feel anxious.
Therapist: I think you are right, and you said it very well. The thoughts really explain your feelings.
Notice how Suzanne’s therapist reinforces Suzanne’s understanding of the relationship between her thoughts and her feelings; she tells Suzanne that she articulated the relationship well, and repeats the connection.
At this point Suzanne’s therapist would introduce the idea of examining her thoughts, to see if there is any evidence for her beliefs. In the next chapter, we are going to cover how to look for evidence for your clients’ thoughts.