An Introduction to Cognitive Behaviour Therapy, 2 edition

8

Cognitive Techniques

Introduction

This chapter introduces a range of cognitive techniques which are used to review and reappraise thoughts and images relevant to the client’s problems. As with any of the interventions used in CBT, their use must be part of a coherent plan and they should not be introduced without a genuine rationale that follows from a shared formulation. Even when following an empirically based treatment protocol, it is essential that you continue to ask: ‘Is this an appropriate intervention for this client at this time? Given the formulation of this person’s problem, can I justify introducing this intervention?’

Remember that not all distressing thoughts are inappropriate. For example, a client might attend a session feeling tremendously upset because he has to take exams in a day or two and is not fully prepared. He might believe that his chances of failure are high, and that he will therefore lose a postgraduate position. These thoughts might be realistic, and if so, your job is not to introduce unrealistic positive thoughts. Instead you might help him use problem-solving skills to minimise the likelihood of failing, or you might help him look at the meaning of losing his position and how he could cope with it.

Timing is also important. For example, Beck et al. (1979) caution that, ‘many depressed patients are so preoccupied with negative thoughts that further introspection may aggravate the perseverating ideation’ (p. 142). Beck and colleagues advocate focusing on goal-directed activities that change the negative estimates of capability, before directly focusing on the cognitions associated with depression. We are again reminded that a cognitive intervention is part of a larger cognitive-behavioural treatment plan.

Presenting a rationale for cognitive work

Clients need to understand the rationale for cognitive work, because you will often be asking them to focus on the most frightening, most depressing or most shameful aspects of their lives and on cognitions that have been ignored or avoided for years. Fundamentally, that rationale rests on your client’s individual formulation, which demonstrates the links between his individual thoughts and his feelings and behaviours. Your client also needs to know that you are not going to require him immediately to share the worst thing he can imagine and to dwell on it. Although he is likely to need to face difficult-to-tolerate thoughts or images eventually, this will be in the context of a respectful, collaborative relationship and will be taken at an appropriate pace.

It might sound obvious, but it is also important that your client understands what is meant by the term ‘cognition’. Beck et al. (1979) describe a cognition as ‘either a thought or a visual image that you may not be very aware of unless you focus your attention on it’ (p. 147). This description nicely introduces the idea that cognitions can be ephemeral and that the client might have to work quite hard to identify them. It also reminds us that images are as relevant as thoughts.

You must guard against your clients identifying unhelpful cognitions as ‘wrong’ or ‘irrational’. This can feed into negative beliefs such as ‘I’m stupid’ or ‘I always get things wrong’. Even if a belief is currently unhelpful, that might not always have been the case. For example, the firmly held belief that ‘It is dangerous to trust’ might have been a helpful and adaptive belief for an abused child, even though in adulthood and away from an abusive environment it might be unhelpful.

Identifying cognitions

A fundamental task of the cognitive therapist is helping clients observe and record the thoughts and the images that run through their minds. It is not uncommon for clients to struggle with this, sometimes reporting that they do not have cognitions or confusing thoughts and feelings. You cannot assume that you can leap in with a couple of well-constructed Socratic questions and discover the cognitive essence of a problem. Your first step will be to help your client learn to ‘catch’ relevant reactions, to discriminate between feelings and thoughts and then to link them so that feelings become a cue for cognitive exploration. Table 8.1 gives some examples.

Table 8.1    Feelings with commonly associated thoughts

Feeling

Thoughts

Depressed    

I am hopeless. The future is bleak and I can’t change it.

Anxious

I am in danger. Something bad is going to happen. I cannot cope.

Angry

I have been disrespected. People are mean to me and I won’t stand for it.

 

 

As the table illustrates, a good general rule for distinguishing thoughts and feelings is that feelings can often be expressed – at least crudely – by a single word, whilst cognitions demand a lengthier description. Clients often find it easier to notice feelings first, rather than thoughts or images. This can provide a useful stepping stone for accessing thoughts. If you encourage clients to begin by focusing on feelings, exploring and elaborating them, you will find that they tend to ‘drift’ into identifying cognitions.

Client:

I don’t know what was going through my mind.

Therapist:

Can you see yourself back there? Get a picture in your mind’s eye?

C:

Yes.

T:

Can you now try to remember how you felt at the time?

C:

Yes – physically sick. Tense.

T:

Stay with that image and those feelings and see if you can tell me more about your experiences that evening.

C:

Well I felt really tense, anxious. My heart was pounding and I was scared, really scared that he would come back and hit me. I thought that he was going to attack me.

In this example, the client first tapped into his physical state, then identified his mood and finally clarified his cognitions. Clients who have difficulty in verbalising cognitions, or claim to have none, can often be helped by focusing on physical sensations.

‘Hot’ cognitions

Beck et al. (1979) emphasised the importance of capturing hot cognitions, i.e. those that seem to be most directly linked to the client’s most significant emotions. Cognitive interventions will be most effective if they target these hot thoughts. When trying to uncover these key cognitions, it can be helpful to ask: ‘Would anyone feel as bad as my client does if they had that thought and believed it as much as he does?’ If the answer is ‘No’ then you might need to keep looking.

Diary-keeping

Records of cognitions are most likely to be accurate if they are made at or near the time they occur. The records can range from simply counting thoughts, perhaps using a golf counter, to quite complicated thought and/or image records (see Chapter 5).

When we ask clients to keep records, we are not simply asking them to collect useful examples: we are also introducing a basic skills training exercise. We are encouraging the client to tune into relevant thoughts, stand back from them and, ultimately, evaluate them. That is a challenging task: just as foreign vocabularies are best learnt by repeatedly writing them out, or piano-playing skills developed by playing arduous scales over and over, this fundamental skill of cognitive therapy is learnt through practice.

Such records are not filled in at random. You should ask clients to record cognitions at times that will cast light on their problems. For example, the following might prompt thought recording:

 

  • the urge to self-harm
  • a mood rating of less than 4 on a 10-point scale
  • an urge to check
  • a binge-eating episode
  • a self-consciousness rating of more than 6 on a 10-point scale
  • a contentment rating of more than 6 on a 10-point scale
  • specific times of the day
  • particular environments.

Typical prompts would include:

 

  • Each time you have an urge to cut or burn yourself which exceeds 5 on a 10-point scale, note the date, time and place and what went through your mind at that time.
  • When your mood drops below 4, write down what you were doing at the time and what thoughts or images were going through your mind.
  • As soon as you can after a binge, record what you ate, the place and time, and what was going through your mind before, during and after the binge.
  • Whenever you take a bus/are in the supermarket/are alone in the house in the evening pay attention to how you are feeling. If you are feeling anxious, rate how high this is and note what is going through your mind.

Figure 8.1    Example of a daily thought record (DTR)

Remember that such records need to be tailored to the individual. Although some excellent thought-record templates exist (Beck et al., 1979; Greenberger & Padesky, 1995), and an example of a thought record is given here (Figure 8.1), it is crucial that any record you use reflects (a) the client’s ability to gather information and (b) the type of information that you and the client need in order to understand the problem better. It is also crucial that the client fully understands how to fill in the record. It is advisable to carry out a dry run in the session, when the client can reflect on a recent example and fill in the form with you.

Below you will meet Judy, who struggled with feelings of panic. This is her therapist’s introduction to the assignment of diary-keeping:

It seems that we have two tasks immediately ahead of us. First, we need to get a better idea of just what is happening for you when you feel so uncomfortable – and keeping this record of events at the time will help us to do this. Second, you described the panicky feelings coming out of the blue and we agreed that we need a way to help you become more aware of what triggers the panic, and feel less overwhelmed by it – tracking your feelings using the diary should help you start to achieve that. But remember, this is our first trial, so we are experimenting really – see how it goes and we’ll see if we have to modify the task at all. Why don’t we run through it now, using the example that you described at the beginning of the session, and see how that would fit in?

Figure 8.2    Judy’s first thought record

Figure 8.2 is an example of Judy’s first thought record, which she completed as a between-session assignment. This was drawn up with her in the session where it had become clear that she could readily articulate her thoughts if she ‘anchored’ herself in the way she was feeling physically. For her, reflecting on her physical feelings served as a powerful reminder of the time at which she was distressed, and her thoughts became accessible. She was also able to evaluate her experiences and put a rating on the severity of both her feelings and thoughts. Had she been very apprehensive about using a rating scale, the thought record could have omitted this and incorporated it later when she felt more confident. Had she not been able to access thoughts, the record could have comprised columns 1 and 2, with column 3 being introduced as she became able to catch her automatic thoughts. Had she found the thought of diary-keeping overwhelming, she could have started by simply keeping a tally of the times she felt panicky each day. If clients are to gain confidence in therapy, it is important that they feel capable of the task that you negotiate with them.

The advantage of rating the degree of physical, emotional or cognitive response was that it helped Judy develop a better ability to discriminate key reactions and it provided a method of quantifying changes over time.

It goes without saying that you must review clients’ diaries. Although some clients find diary-keeping fascinating, to others it can be tedious or distressing. Without a sense of achievement or progress, the client can easily stop completing records, so it is particularly important that you pay attention to them. Record-keeping is another therapeutic task that you should set up as ‘no lose’. If the records are completed, then you have useful information to work with; if the records are not fully completed, then you can explore and work with what prevented your client from being able to complete them.

Turning questions into statements

It is not uncommon for clients’ thoughts to take the form of questions. These can be in the form of rhetorical questions such as: ‘Why am I so stupid?’, or they might be phrased as ‘What if’ questions: ‘What if I fail?’, ‘What if it’s bad news?’ Questions do not lend themselves to reappraisal and testing, so they should be turned into clear statements, with associated belief ratings. Thus, ‘Why am I so stupid?’ might lead to your asking ‘How would you answer that?’ The reply might be: ‘Why am I so stupid? Because it’s my nature, it’s what I am. I am very stupid.’ Now we have identified a definite statement that can be rated for belief and eventually tested.

Similarly, you can explore ‘What if’ questions with an enquiry such as: ‘What if that did happen – what would be the consequences?’; or, ‘What would be the worst answer to that question?’ A typical reply might be, ‘If I failed, then I would never get a proper job and I wouldn’t be able to make a living’, or ‘If it’s bad news then I won’t be able to cope – I’ll go to pieces’. You can then explore these statements further in order to make sense of your client’s fears.

Sometimes clients are reluctant to answer their own questions because the question feels less distressing to them than the statement that lies beneath it. This is a form of cognitive and/or emotional avoidance and, it goes without saying, unpacking this distress needs to be done sensitively.

Enhancing recall through imagery and role play

Not everyone is as able as Judy to catch their automatic thoughts. For others, it may be helpful to use evocative interventions such as imagery and role play in order to recreate a key situation vividly enough for thoughts to become accessible. Possibly the most widely used technique is asking a client to recount a recent experience of the problem in detail (or, if the focus is a unique experience, to recall that specific event). The vividness of recall can be enhanced by asking questions such as: ‘Try to see this in your mind’s eye: can you describe to me what is going on around you, what you felt, how you reacted?’

Judy had some difficulty describing her experiences verbally when she first came to therapy, and imagery helped her to appreciate why she experienced such powerful reactions.

Therapist:

Can you recall when you last felt panicky?

Judy:

In the waiting room here, just a few minutes ago.

T:

Perhaps we could explore that further. Can you imagine yourself back there for a moment? Can you see it in your mind’s eye?

J:

Yes.

T:

If you can, stay with that image and tell me as much as you can about the way you felt. Just focus on that feeling of being there and observe as many of your reactions as you can. See if you can describe things in the present tense.

J:

I am okay but then another person joins me. I feel myself flush and I feel tense and a bit dizzy. I’m thinking that she reckons I’m a lunatic sitting in this place. I get hotter and I know that she’s looking at me and I know that I am going to make a spectacle of myself. Then she gets up and walks out – she can’t bear to be in the same room as such a weirdo.

Judy was asked to describe things in the present to increase the chance of catching the hot thoughts that make sense of her panicky feelings. Earlier in the session it had been difficult to target the hot thoughts because Judy rationalised them with phrases like: ‘I thought that she was looking at me but she might have been thinking of something else’. Although this is a useful perspective for challenging her NATs, at this point it does not help us explain Judy’s extreme reaction.

Imagery work can be a particularly important intervention with adult survivors of trauma who suffer from flashbacks or other unwanted mental intrusions, whether this relates to adult or childhood trauma (for example, Arntz & Weertman, 1999; Ehlers & Clark, 2000; Holmes, Grey & Young, 2005).

Imagery need not be confined to visual images: ‘visceral’ or ‘felt sense’ reactions can also be relevant. For example, a woman with restrictive anorexia might not be able to put into words why she cannot eat an objectively small amount of food. However, questions prompting her to imagine eating might reveal that, although her mind was aware that she would not gain weight, she experienced a rapid sensation of bloating and feeling fat that made eating aversive.

The use of imagery can be a very powerful technique, and for some it can be too evocative. For example, a person who has been through a very traumatic experience might not be able to use imagery without being overwhelmed by traumatic memories. In such cases, it can be prudent to gradually work towards using imagery. The first step would be to discuss the reasons for considering imagery work, then to establish the client’s resilience. An alternative to using the first-person, present tense for recall is to begin with a third-person account in the past tense and gradually move towards capturing a more personal ‘here and now’ account as the client becomes more robust (Resick & Schnicke, 1993).

Role play can also be used to evoke key feelings and cognitions. Judy had recently felt panicky when she tried to pay for petrol, but she could not pinpoint what made sense of these feelings. When her therapist took on the role of cashier and Judy re-enacted the scene, she was able to identify the thoughts: ‘I’m going to do something that makes me look stupid; she’s going to think that I’m stupid; everyone will see that I am stupid’.

Using mood shifts during sessions

Therapy sessions can be a useful source of hot cognitions, so monitor changes in the client’s position, facial expression and tone of voice that may indicate negative thoughts.

Judy, for example, presented as a jovial and humorous character, but there were moments in sessions when her face grew serious and her posture stiffened. Asking: ‘What happened just then? Did something go through your mind?’ frequently resulted in her identifying frightening hot cognitions. In Judy’s case, it was crucial to catch them quickly, as otherwise she tended to trivialise and dismiss them.

Another client, John, had the occasional brief moment of losing concentration and disengaging from the session. Asking what happened at this time revealed that he was experiencing flashbacks of a childhood trauma.

Opportunities for catching hot cognitions during a session are significantly enhanced when using imagery, role play or in-session behavioural experiments.

Clarifying global statements

Negative thoughts are often not very specific, which makes them hard to evaluate. In such cases, it will be useful to ask your client to specify what he means by a particular word or expression. Take, for example, a student who states ‘I am useless’. This invites questions such as:

 

  • In what way ‘useless’?
  • What sort of things do you feel that you cannot accomplish?
  • What sort of things can you achieve?
  • How do you assess your success?

By reflecting on such questions, this student might realise that, rather than being globally ‘useless’, she is achieving in many areas of study but has not been able to achieve her rather high standards in English language.

In response to someone who believes ‘It always goes badly for me’, you might ask such questions as:

 

  • Can you tell me more about the incident that prompted that thought?
  • What else ran through your mind at that time?
  • Have there been times when, in a similar situation, things have gone smoothly?
  • In your review of the last week, can you recall things that went well?
  • What good fortune have you had in your life?

It might become apparent that, although this person felt profoundly pessimistic, things were going reasonably well in many ways. However, with regard to relationships he did seem to have difficulties, and each time a problem arose, he was beset by memories of other failed relationships and felt overwhelmingly negative.

Distraction

This very basic cognitive strategy rests on the idea that we can only concentrate on one thing at a time, so that if we focus on something neutral or pleasant, we can avoid getting caught up with negative thoughts and urges. This can serve two purposes:

 

  1. Breaking unhelpful cycles of thought that might otherwise result in negative moods, increasing preoccupation.
  2. Changing attitudes towards negative cognitions. Instead of getting caught up in them, distraction can help your client achieve distance from them and to see them as ‘just thoughts’ rather than convincing truths about themselves or the world.

Research suggests that distraction is more effective than thought suppression in reducing unwanted cognitions (Wenzlaff & Bates, 2000) and that it is more effective when clients devise a positive distraction that is unrelated to their unwanted thoughts (Wenzlaff, Wegner & Klein, 1991). Thus, thinking about something positive is more distracting than trying not to think about something negative. This is a general finding – we are more successful if we set out to think about something than if we set out not to think about something. You can easily try this out for yourself – try not to think about pink balloons, for example, and your mind will probably fill with pink balloons and you will fail to keep your mind free of them. If, on the other hand, your goal is to think about pink balloons and you try to do this, you will find that you succeed. Furthermore, you can probably manipulate the balloons in your imagination – you can make them rise or fall as you wish or have them explode, for example. This reminds us of the potential control that we have over images.

Distraction techniques that clients can practise include:

 

  • Physical exercise.This is particularly useful when a person is so preoccupied that it is very difficult to come up with mental challenges, or with children and adolescents who might be more physically predisposed than psychologically minded. Physical activities can be overt (e.g. going for a run), discreet (e.g. pelvic floor exercises), challenging (e.g. difficult yoga exercises), or mundane (e.g. household chores). The important thing is that they are engaging for your client.
  • Refocusing.This usually means paying attention to the external environment, and objects or people within it, rather than one’s internal world. Clients are encouraged to describe to themselves qualities of the surroundings such as shapes, colours, smells, sounds, textures and so on. The more detailed the description, the more distracting the task will be.
  • Mental exercise.Mental exercises include tasks such as counting backwards in 7s from 1,000, or reciting a poem, or reconstructing in detail a favourite piece of music or scene from a movie. Another effective distraction is a self-created mental image of a place where your client would like to be – a beach, a beautiful garden, a ski slope – whatever appeals to your client. In order for this to be an effective distraction, the image should be attractive, filled with sensory details and well rehearsed.
  • Counting thoughts.Simply counting the thoughts can help clients get a distance from them – not paying any other attention to them, just counting them, with the same attitude one might have to spotting how many pigeons there are in one’s neighbourhood: ‘There’s one … and another … oh, and there’s another’!

When devising distraction exercises with clients, remember:

 

  • The exercise must suit the client. For example, mental arithmetic and a beach image would not be effective for a person who hates mathematics and is allergic to sand. Your client will only be able to engage in distraction if the exercise is readily accessible and attractive. Build on your client’s interests and strengths.
  • Clients might need several techniques to use under different circumstances. For example, tasks need to be discreet in a public place, whilst in private they can be more overt; physical strategies can be most accessible when a person is highly preoccupied, and mental strategies more usable at lower levels of preoccupation.
  • Distraction can be used in behavioural experiments to test predictions such as ‘I can’t stop thinking about x’, or ‘I cannot get the worries out of my head’.
  • Distraction will be counter-productive if used as a long-term avoidance or safety behaviour. If your client develops a belief that he is only coping because he uses distraction, rather than building up confidence that he can take command of his problems, then distraction will be of limited benefit and could actually undermine his confidence.
  • Often distraction does not fundamentally change the unhelpful cognition, so it is not necessarily a good strategy for the long term: hence the need for the other strategies described in the remainder of this chapter.

Identifying cognitive biases

As clients become adept at identifying relevant images or thoughts, they can usefully learn to look out for cognitive biases (see Table 8.2). These are exaggerations of thinking errors that we all experience from time to time when we are emotionally aroused. They reflect normal fluctuations in our information-processing styles, and they only become a problem when the bias is chronic or too extreme. For example, the first bias in the list below is ‘dichotomous thinking’ – an ‘all or nothing’ style which fails to incorporate the possibility of shades of grey. This type of information-processing style increases with stress levels (Kischka, Kammer, Maier, Thimm & Spitzer, 1996), and, indeed, it may be appropriate when we are under threat. If a car swerves towards mine, it is appropriate that I think ‘life or death!’ and swiftly manoeuvre out of the way – it would be inappropriate for me to lose valuable time considering the many less dramatic options. If, however, this was my habitual way of responding to moderately stressful situations, I would probably very quickly develop an anxiety-related problem.

Table 8.2 contains four groups of cognitive biases: extreme thinking, selective attention, relying on intuition and self-reproach. Note that the specific categories within these groups are not mutually exclusive.

Table 8.2    Common cognitive biases

Extreme thinking

 

Dichotomous thinking

Viewing things in ‘all or nothing’ terms without appreciating the spectrum of possibilities between the two extremes

 

Things are ‘good or bad’, ‘successes or failures’. Typically, the negative category is more readily endorsed

 

Example: Nothing is ever going to go right for me. I can trust no one. I am a total failure.

Unrealistic expectations/high standards

Using exaggerated performance criteria for self and/or others

Using ‘shoulds’, ‘oughts’, and ‘musts’

Examples: Unless it’s the best, it doesn’t count. I should get full marks. Mistakes are unacceptable. I must please everyone.

Catastrophisation

Predicting the very worst, sometimes from a benign starting point

 

This may happen very rapidly so that it seems that the client has immediately leapt to the most awful conclusion

 

Examples: I made a mistake; my boss will be furious; my contract won’t be renewed; I will lose my job; I will lose my home; my wife will leave me; I will be poor and lonely.

Selective attention

 

Over-generalisation

Seeing a single negative event as an indication that everything is negative

 

Examples: I have failed an interview – I’ll never get a job. This relationship is going badly – I’ll never find a partner. She let me down – I can trust no one.

Mental filter

Picking out and dwelling on a single negative feature without reference to other, more benign events

 

Focusing on the one thing that went badly in an otherwise successful day. Forgetting achievements and compliments but dwelling on a single criticism

 

Example: One of my exam marks is low – this is terrible – I’m really no good at anything.

Disqualifying the positive

Rejecting, down-grading or dismissing as unimportant any positive event

 

Examples: He is only saying that to be nice. She is probably trying to get something out of me. This was a small achievement – others do better.

Magnification and minimisation

Exaggerating the importance of negative events and underestimating the importance of positive events

 

Example: What a mess up I made of that deal. Yes, I got the terms that my boss wanted but I didn’t handle it well.

Relying on intuition

 

Jumping to conclusions

Making interpretations in the absence of facts to support them

 

Examples of jumping to conclusions divide into two categories:

 

(i)   Mind-reading: I just know that they were all laughing at me behind their friendly faces

 

(ii)  Fortune-telling: When I meet him, he will dislike me.

Emotional reasoning

Assuming that feelings reflect fact

 

Examples: I feel as though I can’t cope, so I’ll have a couple of drinks first. I feel awful when I get angry, so it must be bad to get angry. I feel unattractive so I must be.

Self-reproach

 

Taking things personally

Assuming responsibility if something (perceived as) bad happens

 

Examples: The dinner party did not go well: it was my fault for being tense and causing others to feel uncomfortable. Two students left my lecture early; I must have been boring.

Self-blame or self-criticism

Seeing oneself as the cause of a bad event or criticising oneself without cause

 

Examples: I feel ill; I must have brought it on myself; I can’t catch up with my work; I must be stupid and lazy.

Name-calling

Attaching harsh and demeaning names to oneself

 

Examples: Idiot! I am so stupid. What a fool I am.

 

Judy was given a copy of the summary of cognitive biases in Table 8.2, and she smiled and said: ‘I can achieve something: I can tick all these!’ Like many clients, she readily recognised a tendency towards cognitive biases or ‘crooked thinking’ (Butler & Hope, 2007). Her amusement at realising this helped her to stand back or ‘decentre’ (see next section), and, as it was difficult to maintain a fearful ‘mindset’ when she laughed, she was much better placed to see alternative, more positive possibilities. Table 8.3 is an extract from her diaries, identifying the cognitive biases pertinent to her.

Table 8.3    Judy’s extreme thinking

Thoughts

Cognitive biases

I am going to have a panic attack …

Catastrophising

… and all eyes are upon me.

Jumping to conclusions

They will think I’m crazy.

Mind-reading

People on the forecourt are noticing that I’m a wreck.

Mind-reading

I am a wreck.

Name-calling

I’m going to have a panic attack.

Catastrophising

 

 

In summary, so far we have outlined the need to help the client:

 

  • understand and identify cognitions, using Socratic enquiry coupled with imagery and role play if necessary;
  • record cognitions;
  • link situation, thoughts and feelings, so that you are both able to say: ‘It’s no wonder that…’;
  • use distraction for short-term coping;
  • become aware of cognitive biases.

Now your client is ready to appraise the automatic thoughts and images that are giving rise to problems.

Appraising automatic thoughts and images

Taking a step back, or ‘decentring’

Beck et al. (1979) described decentring, or the ability to view cognitions as mental events rather than as expressions of reality, as a core component of cognitive therapy. Rather than buying into the emotionally laden content of a cognition, the client stands back and observes it, recognising that a thought is an opinion, not necessarily a fact. Decentring is also termed ‘meta-cognitive awareness’, meta-cognition being defined as any knowledge or process that is involved in the appraisal, monitoring or control of cognition (Flavell, 1979). Clients may be able to achieve this if they are able to label the thinking process rather than dwell on the content. You might hear phrases like: ‘There’s my all-or-nothing thinking again’, or ‘I’m catastrophising here’, or ‘It’s my abandonment fear kicking in’. Such responses indicate that your client has achieved meta-cognitive awareness. The past decade has seen decentring playing an important part in CBT since the introduction of mindfulness meditation into CBT practice – see Chapter 17, which reviews such developments.

Understanding the origin of a cognition

When clients are learning to view their cognitions objectively, they can easily label themselves as ‘stupid’ or ‘silly’. You need to help them appreciate why it makes sense that they have such unhelpful thoughts, or why it made sense at some time in their lives. One way of doing this is to ask them to consider the evidence or experience that supports a hot thought. Problem cognitions rarely, if ever, come out of the blue. There is usually an earlier experience that renders them understandable. Aim to help your client recognise that there might be a reason why they drew certain conclusions, so that they can begin to conclude: ‘It’s no wonder that …’ or ‘I can understand why …’ when they review their automatic thoughts.

The student in the earlier example, who believed ‘I am useless’, had attended a very demanding school where the pupils had been encouraged to excel in all subjects. Holding high standards at that time both helped her to cope with the culture of the school and, because she was academically able, to achieve and gain a great deal of reinforcement for doing so. Later, at a different time in her life, these same high standards proved stress-provoking and often unattainable, thus promoting the belief ‘I am useless’.

The young man who felt that ‘It always goes badly for me’ had indeed had a number of broken relationships, so it was understandable that he might be pessimistic. He believed that he could protect himself against major hurt by anticipating the breakup of a relationship, and so it was not surprising that he had maintained a pessimism within relationships. However, he now discovered that this attitude diminished his enjoyment of, and commitment to, relationships.

Below are Judy’s explanations for her automatic thoughts. When appraising ‘They will think I’m crazy’, the therapist asked:

 

  • Can you recall a time when you did not feel like this, when getting panicky did not make you assume that others would think that you were crazy?
  • Can you recall when you began to hold this view?
  • Can you be more specific?

Figure 8.3    Judy’s automatic thoughts

It transpired that Judy’s attitude had very much been influenced by her mother telling her not to show emotions publicly, lest people assume that she was weak and strange (see Figure 8.3).

Weighing up pros and cons

In cognitive therapy we look for the reasons why what seems like an unhelpful reaction or response makes sense to the client. This is one reason why we ask our clients to consider the advantages of holding cognitions that are, ultimately, not in their best interests. It is useful to encourage clients to explore the pros (as well as the cons) both in the short and the long terms, as some cognitions might only have limited advantages; some give short-term relief but long-term disadvantage; some give short-term discomfort but perceived long-term advantage. For example, permission-giving thoughts like ‘I’m useless so I might as well give up’ give a good deal of short-term relief by encouraging avoidance, but may compound problems in the long term; in eating disorders, the thought ‘I am not giving into the hunger pangs’ might create short-term discomfort but can confer a sense of control in the long term. An advantage of negative thoughts is often a perceived protection, e.g. ‘If I anticipate having a panic attack, it won’t take me by surprise’, or ‘If I expect the worst from people, I won’t be disappointed’. When the pros and cons of cognitions are considered in detail, the resilience of a negative thought often becomes more understandable. Some clients will explain to you that an advantage of holding certain negative beliefs is that they reflect the truth (‘I could have a panic attack’; ‘I am alone’; ‘I’m hopeless in social situations’). Although there may be a grain of truth in some negative cognitions, it is often exaggerated.

Next, we enquire about the disadvantages of having the thoughts or beliefs (again in both the short and long terms). This step helps loosen up a conviction that the negative thought is somehow protective and this can sometimes improve the client’s motivation to change. In Judy’s case, the disadvantages of predicting that she would have a panic attack were that she increased her physical discomfort, she made it more likely that she would have a panic attack, and she was always miserable in challenging situations. The disadvantages of assuming that others judged her negatively were again that she was always distressed in challenging situations, and she was inhibited about doing many things that she might otherwise enjoy.

Sometimes referred to as a cost–benefit analysis, balancing pros and cons is an approach that encourages a widening of the client’s perspectives, which is particularly useful when it is not possible to conclude whether something is true or not but, rather, what is most useful on balance.

Another related strategy is ‘reframing’, which facilitates the development of a wider perspective by prompting reflection about the ‘other side of the coin’. Consider, for example, the ambitious father who spends most of his evenings at work and missing out on time with his children: the uncomfortable prospect of reducing his workload could be reframed as making more time for his children. Or consider the extreme dieter who, in striving for control of her weight and shape, is functioning less well in her social and work life because of her preoccupation with dietary restriction: she could reframe the apparent benefit of extreme dieting as the enemy of her work and social life.

When exploring the pros and cons, and reframes, you should, of course, be nonconfrontational, empathic and collaborative. Such exercises are aimed at enabling and enlightening your client rather than illustrating how wrong they might be. Carried out in this way, this approach is a particularly helpful one in engaging and motivating clients who are ambivalent about change (Miller & Rollnick, 2002).

What is the worst thing and how would you cope?

Although it is a difficult prospect for some clients, asking them ‘What is the very worst thing that could happen?’ can be an extremely valuable question. It prompts them to name the fear (which cannot otherwise be tackled), and the answer clarifies the ultimate problem that needs to be resolved. The corollary question ‘… and how would you cope?’ then kicks off the process of problem-solving. When a solution for the worst-case scenario has been devised, it often takes the heat out of catastrophic predictions.

Judy’s worst fear was that she would have a panic attack in public. The enquiry about how she might cope was, in itself, a revelation to her. She had never contemplated coping, and she had never viewed the panic attack as having an end – her projected fear had been too vague. Now, with the help of her therapist, she was able to generate some ideas for managing the situation: she would try to find somewhere discreet, she would try to talk herself through the experience, and she would rehearse a statement to explain her predicament to anyone who approached her. Through this exercise, Judy became more confident that she could cope with the worst outcome, and it frightened her less.

Identifying cognitive themes

It is usual to find themes of either process or content running through thought records. Process themes might include dichotomous thinking as the most prominent form of information-processing, or withdrawal as the reaction to perceived interpersonal conflict. Themes reflecting the content of cognitions might include rejection, threat, shame, anger and so on. Some themes are more common in particular disorders: for example, the need for control and perfectionism is often associated with eating disorders, loss and shame with depression, threat with anxiety disorders. The value of identifying such themes is twofold.

First, recurrent themes can be challenged thematically – that is, developing a repeatable challenge for addressing the pervasive shame or recurring sense of loss. This is much more efficient than having to generate a novel challenge for each problem cognition. Second, themes can give insight into pervasive core beliefs. Studying Judy’s diaries revealed two dominant themes, one concerning the self (I am crazy) and one focusing on others (They are judgemental). Managing the latter core belief is illustrated later in this chapter.

In summary, we have so far described how you can help your client learn to:

 

  • identify unhelpful cognitions;
  • identify cognitive biases;
  • stand back from them and view them as unhelpful but understandable thoughts;
  • question their utility and validity;
  • consider the worst outcome, and develop solutions for this.

Thus, your client can develop a more objective and wider perspective on his negative thoughts and beliefs.

Developing new perspectives

The groundwork done, now it is time to reflect on problem cognitions and reappraise them: the notion of there being alternative, less-discomforting possibilities can be entertained. There are several techniques that can be used to develop new perspectives.

Reviewing evidence for and against: getting a balanced view

Armed with an enhanced perspective on the situation, your client can now review what supports, and what undermines, his initial conclusion. This is illustrated in the example from Judy’s diary in Figure 8.4, where she reviews why it is understandable that she draws a negative conclusion and then she goes on to balance this with evidence that does not support that conclusion.

A useful strategy for gathering evidence to inform a more balanced view is an elaboration of decentring, in which you ask your clients to distance themselves from the thought or image enough to imagine a number of different perspectives. This can be prompted by questions such as:

 

  • Can you think of other possibilities? Other explanations?
  • What does not fit with your initial conclusion?
  • If someone you cared about had this thought, what would you want to say to them?
  • If someone who cared about you knew that you had this thought, what might they say to you?
  • If someone you knew had this thought, or struggled with this situation, what might they say to themselves? How might they cope?
  • Are there things that you are overlooking when you are distressed?
  • Have you been in similar situations and not felt or thought like this?
  • Have there been times when you have felt like this and coped?
  • When you are away from this situation, what do you think?
  • If you ‘fast-forwarded’ five years from now, how would you view this situation?

The ‘best’ sort of evidence is factual and objective. So, although conclusions such as: ‘I think that a friend would say that there was nothing to worry about’ might begin to shift a person’s perspective, objective experience such as: ‘I have been in this situation at least 15 times and never had a panic attack’, or ‘I get light-headed every day and I have not once fainted’, or ‘In my entire school experience I have never failed an exam’, will carry more weight.

Figure 8.4    Judy’s diary

Prompting for a broader range of possibilities can elicit coping statements and even plans for action.

When Judy was asked these questions in therapy, she readily generated helpful self-statements (see her diary, Figure 8.4) as well as strategies such as self-calming. She remembered that a friend had once told her that adopting a Pilates posture helped her to combat stress. Judy had attended Pilates classes but then neglected her practice – she decided to revise them and found it helpful.

This reminds us that familiar, comfortable strategies that have validity for the client will be most readily adopted and maintained.

Addressing cognitive biases

Dichotomous thinking is readily moderated by introducing the notion that there is a range of possibilities between the extremes. This technique is also described in Chapter 16 under schema-focused work, as it is a really useful strategy for both ‘straightforward’ and for more ‘complex’ patients.

In order to help clients combat dichotomous thinking styles, first help them identify the relevant extremes.

For example, Judy tended to assume that she felt calm or panicky (which meant that if she did not feel calm she anticipated that a panic attack was imminent).

Next encourage your client in entertaining the idea that there might be stages between the extremes and in doing so generate examples that illustrate different points on the spectrum.

Below is Judy’s new perspective of her emotional experience: she was able to recognise different stages in growing panicky.

This exercise was helpful in several ways. It illustrated the range of possibilities, which curbed her tendency to jump to the most catastrophic conclusion; it provided reassurance that she could feel panicky without progressing to a panic attack; and, in discussing the variations in her feelings of nervousness, she realised that she might misinterpret excitement as the warning signs of panic.

A different client, Alan, tended to view himself as a ‘success’ (i.e. he completed a piece of work to a very high standard) or a ‘failure’ (i.e. he did not regard his work as the very best that he could achieve). This made him very vulnerable to mood swings as he felt really good about himself when he had met his exacting standards but very bad about himself when he failed to do so. It also had an impact on his behaviour as he tended to withdraw and drink when he felt bad about himself and this, in turn, fuelled his depression.

In therapy he was able to construct a continuum of performance which helped him become more flexible in his appraisal of his work.

He then considered what he would find acceptable in others and he realised that he would be quite happy if those around him were performing at a ‘Good but not perfect level’ and that he would consider ‘Excellent’ to be a bonus. He also realised that he could accept the occasional poor piece of work from colleagues, as long as this was not habitual. When he had completed this piece of continuum work, he found that his attitude towards himself was more lenient.

Sara had a different issue from Judy or Alan – she was dichotomous about trusting others. She tended to trust people absolutely until they let her down (or she perceived that they had let her down). At that point they became 100% untrustworthy in her view. As you can imagine she had difficulty in maintaining relationships and this was a source of great distress to her. In therapy Sara devised two useful continua: one reflected the degree of trustworthiness of those in her social and occupational circle and the second reflected information that was appropriate to share with people of different levels of trustworthiness.

  1. Whom I can trust (based on how well I know a person and what I know of their behaviour so far)
  2. What I will share depends on how trustworthy a person is

The first continuum helped Sara learn to review how well she knew a person and what she knew about them before considering how well she might trust them. The second helped remind her not to be either too open or too secretive. This helped her establish more balanced relationships where she shared information about herself with trusted friends.

Selective attention to the worst possibilities can be tackled by prompting your client to search for other possibilities by asking himself questions such as:

 

  • Are there other ways of looking at this?
  • Do I have strengths/assets/resources that I am ignoring?
  • What other possibilities might a friend see?
  • Am I missing something?

Such questions prompt decentring – standing back and viewing the bigger picture.

By doing this, Judy was able to appreciate that not all unpleasant sensations heralded a panic attack, that not all eyes were upon her and that she had previously shown a composure and resilience which stood her in good stead. Alan learnt to consider his previous performances (which were generally very good) rather than always noting the one that disappointed him, while Sara learnt to give herself a little time to review the situation before drawing too rapid a conclusion about a person’s trustworthiness.

Relying on intuition can be curbed if a client accepts that feelings or unsubstantiated beliefs do not necessarily represent reality. There are many examples that clients can consider to support this idea: for example, children’s strong belief in Father Christmas does not mean he is real; our ancestors’ belief that the world was flat did not stop it being spherical; an emotionally deprived child’s feeling that he is bad does not mean he IS bad; and ‘feeling ten feet tall today’ does not mean that you need to duck when you go through doors! Whether mind-reading, fortune-telling or assuming that a feeling reflects a fact, clients can begin to question the truth of such intuitions and ask ‘… is this supported by some evidence?’ or ‘… do I have experiences which suggest that this is the case?’ or simply ‘… how do I know?’ One simple strategy that Judy worked out for herself was asking friends what they felt or what they intended by a remark, instead of ruminating on what her friends might feel or think; Alan began to routinely ask trusted colleagues to appraise his work and Sara carried around copies of her continua which she would refer to in order to remind her of the reality of her relationships.

Self-reproach can be very undermining – just as it would be if severe criticism came from someone else. However, it can be moderated by prompting the client to ask questions such as:

 

  • Is it really so bad?
  • Am I blaming myself unfairly? Who else might be responsible?
  • Whose voice is this? … and are they an expert?

When Judy reflected on her thought ‘They w ll think that I am crazy’, she realised that this was [the memory of] the voice of her mother, who restricte emotional expression within the family and warned her children that others would view them as weak and silly if they were not in control of their emotions. She quickly realised that her mother was not an expert in social psychology and that her view was extremely unhelpful. As a result, Judy was able to dismiss this thought altogether.

Alan realised that his inner critic was driven by a fear of being seen to be flawed and weak and that this had arisen as a way of coping with the self-doubts he had developed at school when he was bullied. He had for years blamed himself for this, assuming that he had brought it on himself by being ‘geeky and weak’. In therapy, he considered who (or what) else might have contributed to the bullying. He came up with quite a list: the particular girls and boys who chose to pick on him; the schoolteachers who did not notice or help him when he tried to ask for help; the school itself because it supported a culture of brutality amongst the children; his parents for never offering him a shoulder to cry on. By the time he had compiled this list, he perceived his own role in the bullying had diminished and he was more compassionate towards himself.

Using imagery and role play

The more experiential strategies of imagery and role play can be invaluable in shifting and manipulating unhelpful cognitions. An excellent review of the use of imagery can be found in Hackmann and Holmes (2004).

Rehearsal of new possibilities can be carried out in imagination and this can be helpful in several ways. It can be used for the client who is:

 

  • building up his confidence, step by step and who is not yet ready to face his challenges in real life: for example a boy with a fear of snakes holding increasingly challenging images of snakes as a prelude to visiting the local zoo and handling one;
  • not able to practise in real life: for example, a woman with a fear of flying repeatedly imagining herself travelling by plane – for financial and practical reasons it would not have been possible to repeat this experience in real life;
  • preparing to taking on a challenge: for example, Judy imagined herself walking into a public area and feeling calm – reviewing this image helped her to feel more calm and confident when she took on a social task for real.

Transforming problem images can also be helpful. The horror of recurrent nightmares can be diminished through repeatedly imagining a new and bearable (or even pleasant) ending (Krakow et al., 2001); traumatic memories can be rescripted so that the meaning of a present threat is removed (Layden et al., 1993; Ehlers & Clark, 2000); a hostile self-image can be transformed into a compassionate one (Gilbert, 2005); a simply unpleasant mental picture can be changed into one that is tolerable, and clients can be encouraged to develop soothing, comforting images that can help them calm themselves.

As well as constructing such new narratives and/or mental pictures, you can help clients to overcome problem images via image manipulation techniques, such as imagining the unwanted image on a TV screen and then manipulating the image by changing the volume, fading the picture and so on, or ‘morphing’ characters in the image to make it more tolerable.

Judy had an unhelpful image of people looking at her judgementally, but she reduced its impact by shrinking the onlookers in her imagination. Alan had a similar image and he was able to transform the expression on the faces of the onlookers to that of acceptance and warmth.

An approach advocated by Padesky (2005) is to ask clients to create a vision of how they would like things to be. They are encouraged to make this mental picture as vivid as possible and to identify the assumptions that they would have to live by in order to realise the vision. Behavioural experiments can then further establish confidence in the new image.

For example, Judy’s image might be walking into a public area and feeling calm. The assumptions that would facilitate this might be ‘People who know me accept that I am basically OK, and strangers are not that interested in me’.

Imagery can be incorporated into role play. Beck et al. (1979) described client and therapist taking on critical and supportive inner voices and creating a dialogue to strengthen the supportive voice; Padesky (1994) described using ‘historical role play’ or ‘psychodrama’ to rework or reconstruct earlier unhelpful interpersonal interactions; Gilbert (2005) advocated using the Gestalt two-chair technique as the basis for building up an image of a compassionate self and diminishing the inner critic.

When Judy realised just how unhelpful her mother’s influence had been, she felt less anxious, but she was angry and these feelings were uncomfortable. She resolved them in session by first imagining her mother in an empty chair. She then ‘told’ her mother of the consequences of her mother’s attitudes and the anger that she now felt. In this exercise, she also agreed to take on the role of her mother responding to Judy’s statement. In this role, ‘her mother’ explained that she had been trying to protect Judy from being victimised as she once was. This was the first time that Judy had considered her mother’s perspective and it helped her to dissipate her anger.

Drawing new conclusions

By this point, your client has viewed the original negative thoughts from several angles, has built up a wider perspective and has entertained new possibilities. Now it is time to condense this awareness into pithy, memorable and believable new conclusions. Judy’s new conclusions are shown in Figure 8.5, along with her ratings of belief in each statement.

It is interesting that the predominantly intellectual task of analysing her cognitions had resulted in her developing a 100% belief that feeling was not fact, and that it was unlikely that others would think that she was crazy; however, her belief that the sensations of panic would not lead to a panic attack was not so compelling (80%). It is also interesting that, although she developed a new belief (‘My feelingthat others are looking does not make it fact’), which she believed in the session, she was not wholly confident that she would be so convinced when in a challenging situation.

Figure 8.5    Judy’s conclusions

This reminds us that therapy does not end with the intellectual achievement of shifting cognitions. There is also scope for behavioural testing both to establish their veracity and to consolidate realistic new attitudes.

In summary, in reappraising cognitions and developing new perspectives, we encourage clients to:

 

  • de-centre, standing back from the emotionally loaded cognition;
  • address cognitive biases through tackling extreme thinking, selective attention, relying on intuition and self-reproach;
  • use imagery and role play to enhance this process;
  • draw new conclusions, which can then be reality-tested.

Testing automatic thoughts and images

The importance of testing out new possibilities or perspectives is elaborated in Chapter 10, which describes the role of behavioural experiments in cognitive therapy. The validity of a new cognition is usually enhanced if it stands up to ‘road testing’. In addition, the new possibility will be more memorable if a client takes it from a conceptualisation or a possibility through to an active experience.

Judy decided to ‘research’ her new conclusions by collecting information that could confirm or disconfirm them. With regard to her new prediction that the feelings of panic would not necessarily herald a panic attack, she planned to provoke panicky feelings and record what happened. She had begun to appreciate that panic was not ‘all or nothing’, and she devised a scale of her panicky sensations to assess degree of change. She also planned to involve her friends in her research, for example by asking them to observe the reactions of others and to note if Judy was the subject of much attention (see Figure 8.6).

Modifying core beliefs

There is some confusion in the literature between ‘core beliefs’ and ‘schemata’. The terms are not interchangeable because a schema is generally considered to be more complex than a core belief, but the latter can reflect a ‘summary label’ for a schema. For example, the core belief ‘I am stupid’ is a useful cognitive label which summarises the thoughts, feelings and physical sensations associated with believing that one is truly stupid. This section will focus on core beliefs; in Chapter 17 we discuss the nature of schemata.

Figure 8.6    Judy researches her new conclusions

We should not assume that core beliefs are always difficult to identify, as they may be expressed as automatic thoughts. In the earlier example, the student readily identified ‘I am useless’ as a key cognition, which might well be a core belief. If a core belief is not expressed as an automatic thought, then guided discovery and the downward arrow technique can often uncover it.

It is also important not to assume that a core belief is necessarily resistant to change. Judy rapidly shifted a long-standing core belief (‘I am crazy’) when she realised that her mother was not an expert in character analysis; it is not uncommon for core beliefs to shift as a consequence of therapy that targets automatic cognitions (Beck et al., 1979). However, some belief systems are more rigid, and augmented techniques have developed to specifically target them (see Chapter 16).

In their self-help book, Greenberger and Padesky (1995) describe a collection of strategies (see Box 8.1) aimed at modifying core beliefs. They emphasise that, because core beliefs can be robust, these strategies are likely to have to be used over several months before they have significant impact. They therefore need to be negotiated carefully with clients so as to avoid disappointment and demoralisation. The strategies include:

Box 8.1

 

  • Carrying out behavioural experiments to test the predictions of core beliefs.
  • Recording evidence that a core belief is not 100% true.
  • Identifying alternative (more helpful) core beliefs.
  • Carrying out behavioural experiments to test the predictions of alternativecore beliefs.
  • Recording evidence that supports an alternative core belief.
  • Historical tests of new core beliefs.
  • Rating confidence in new core beliefs.

Judy felt that she needed to work on a core belief that others were judgemental. The behavioural experiment that she devised was a data-collection task. Over several weeks she asked friends what they thought of people who had made a mistake or appeared ‘silly’ to her. Her prediction was that her friends would judge others badly. Figure 8.7 shows two examples from her record.

Judy then made a log of such findings, which she headed: ‘Evidence that my belief is not 100% true’. On occasion, her opinion polls supported her prediction, but she was now able t put this in the context of the data that showed that this was not true 100% of the time.

Of course, you might discover that your client’s prediction is repeatedly confirmed. If so, it merits investigation: is your client only mixing with like-minded people? Is your client filtering out disconfirming evidence before it can reach the page? You might consider that schema-focused techniques could be more helpful if negative core beliefs seem particularly resilient (see Chapter 16).

Figure 8.7    Judy collects data

Judy, however, reviewed the responses that she had collected, and concluded:

It is true that some people are judgemental, but most of my friends are actually quite generous in their opinions of others. Furthermore, I find that those who are more judge-mental are not amongst the friends that I most value and I tended to dismiss their harsh appraisals.

She was then able to identify a new core belief: Some are harshly judgemental but most people are generous. At first, she believed this at a 50% level. In order to strengthen this new, more comfortable belief, she began a log of evidence that supported her new belief. She was diligent in maintaining this log, and after a few weeks her rating of her conviction in the new statement was 98%.

In order to strengthen a new core belief that is counter-balancing a less helpful one from the past, Greenberger and Padesky (1995) advocate the use of a historical test of the new core belief, where the client reviews his life history looking for evidence consistent with the new belief.

Although Judy was already successful in developing a new fundamental belief, she was keen to reinforce her progress and chose to carry out this retrospective analysis. She was, by now, much more able to ‘see’ the evidence that supported her new belief and found that many of her earlier experiences strengthened her new conviction.

Problems

The client seems to avoid exploring cognitions

Sometimes a client simply wants to talk about feelings. In some such cases, supportive counselling may be more appropriate. For instance, when people are first coming to terms with loss or trauma and realising the scope of their problems, they may need time just to talk them through. Alternatively, clients who are ambivalent about therapy might need an approach that emphasises ‘motivational interviewing’ (Miller & Rollnick, 2002).

Other clients focus on exploring feelings because they believe that this is the best use of therapy, so they may need to be reminded of the method and strengths of CBT and how this approach differs from other forms of psychotherapy.

Avoidance of exploring cognitions also occurs when clients are afraid of the content of their thinking. Sometimes the cognitions are never properly reviewed, but the sufferer has a sense of their awfulness or is reluctant to revisit cognitions that trigger other painful feelings – the shame of the sexual-abuse victim, for example. In these instances, you need to invest time in creating a sense of safety in the sessions that will allow your client gradually to confront distressing thoughts.

The cognitions are so fleeting that the client has difficulty identifying them

This is not uncommon and it is helpful if the client realises that it is in the nature of NATs to be elusive. Behavioural experiments, done to provoke negative thoughts rather than to test them, can be useful in making the thoughts more obvious (see Chapter 9).

Some thoughts don’t readily map onto language and are better described as a visceral ‘felt sense’ (Kennerley, 1996). For example, clients with body dysmorphic disorder might report ‘feeling’ disfigured, a person with OCD might describe ‘feeling’ dirty, or someone with disgust-based PTSD might ‘feel’ this physically. Such felt senses can be worked with, but most cognitions can be verbally articulated, given encouragement and time.

Challenging has little or no impact

In such cases, the first question you must ask yourself is: ‘Is the focus of therapy correct?’ This will require revisiting the formulation and revising it if necessary.

It is also important to check out with your client what keeps him believing the old thoughts, or what stops his believing new alternative thoughts. There may be pieces of evidence, safety behaviours or other blockages that have not been fully dealt with. Or you may not be focusing on the ‘hot’ thought. Behavioural experiments can often be critical in ensuring that new learning is felt at a gut level rather than just heard intellectually.

A final possibility is that the problem is driven by a particularly rigid and inflexible belief system and so a more schema-focused approach is called for.

 

Summary

 

  • This has been a lengthy chapter because the cognitive techniques of CBT are both crucial and diverse. There are techniques for:

o    observing key cognitions

o    distracting from problem cognitions

o    analysing them and

o    synthesising new possibilities …

o    … which can be evaluated through behavioural experiment.

  • Your first step is identifying key cognitions – predominantly through the use of Socratic enquiry and DTRs. Over time, the DTRs can be used to observe, analyse and to synthesise information but the use of them must be paced to match your client’s needs and abilities.
  • The cognitive strategies you use to help your client identify problem cognitions and later challenge them will be determined by your formulation. Each intervention needs to be justified and a rationale shared with your client. It is important not to pull a technique ‘out of the hat’.
  • Although the predominant focus is in the present, we have also seen that some cognitive strategies review or even confront the past, and although the predominant focus is on NATs and underlying assumptions, cognitive techniques can be used to address core beliefs.
  • Interventions can be verbal, visual and experiential and can focus on cognitive content or cognitive process. You can be creative with cognitive strategies – but always make sure that you can justify your decision.

Learning exercises

Review and reflection:

 

  • Cognitive techniques are, of course, central to CBT. In reading this chapter were you surprised by any of the sections or the statements made – if so what did you not expect to see? If you were surprised by something in this chapter, was it welcome or worrying?
  • Overall, what is your reaction to reading about strategies to identify and challenge problem cognitions? Do the techniques seem to fit with your preferred style of working? Can you see how this chapter builds on the knowledge you have gleaned from earlier chapters? Are there aspects of identifying or challenging problem cognitions which feel wrong to you – if so, with what are you uncomfortable? Try to tease out your doubts and uncertainties.
  • Do you have doubts about your ability to use these techniques – if so, what are your worries? Are their certain aspects of this predominantly cognitive work for which you need further training?

Taking it forward:

 

  • An excellent way of gaining experience of using cognitive techniques is to use them on yourself. So:

o    Identify a problem issue for yourself, perhaps a common work-related issue such as being avoidant of certain topics or fearful of certain responses from your client, or you could address worries which you have about using cognitive techniques.

o    Keep a record of the cognitions (thoughts and images) that are associated with your difficulty.

o    Try to ‘stand back’ and identify cognitive biases and review the content of your cognitions.

o    Then try to re-evaluate your troublesome cognitions.

  • Reflect on how you got on with doing this for yourself – what did you learn not only about your own difficulty but about taking on this task? Consider how your client’s will feel when asked to do something similar. How can you make that task most acceptable and achievable for them?
  • If you feel uncertain about the usefulness of the strategies described in this chapter or if you feel that you need further training, find out what courses, workshops, supervision and reading are available to you and make a concrete plan to make use of them.

Further reading

Greenberger, D., & Padesky, C. (1995). Mind over mood. New York: Guilford Press.

This self-help book might be 15 years old, but it contains the most clearly described and systematic approach to identifying and testing problem cognitions. It is useful for both clients and practitioners – particularly novice practitioners who can benefit from using the book on themselves.

Burns, D. (1980). Feeling good: the new mood therapy. New York: William Morrow.

This self-help book for depression is even older, but it has stood the test of time and remains an excellent resource for both practitioner and clients. It also guides the reader through the stages of CBT but it is particularly helpful as Burns addresses some of the common assumptions that can fuel depression (and other problems). For example, perfectionism and assuming that performance equals worth, are explored in detail and the reader is given many ideas for combating such unhelpful assumptions.