01 - 15. Responding to Automatic Thoughts

15. Responding to Automatic Thoughts

T he previous chapter demonstrated how to help clients evaluate important negative automatic thoughts and determine the effectiveness of their evaluation in session. But when these same thoughts arise in their minds during the week, clients may not remember their responses. They will also experience additional important automatic thoughts between sessions that you didn’t identify. You will find the answers to these questions in this chapter: How do you help clients compose therapy notes to read between sessions? How do you teach clients to use a worksheet to address other automatic thoughts between sessions? What should you do if a worksheet isn’t helpful enough? Make sure that clients have recorded robust responses in writing (on paper or an index card, in a therapy notebook, or on a smartphone) or in an audio format (using a recording device or an app) to automatic thoughts you’ve addressed in session. To respond to other automatic thoughts between sessions, you can teach clients how to use questions from the previous chapter (Figures 14.1 and 14.2). Or you can use the Testing Your Thoughts Worksheet (Figures 15.1 and 15.2) or a Thought Record (Figures 15.3 and 15.4) or another technique described later in this chapter. RESPONDING TO AUTOMATIC THOUGHTS

COMPOSING THERAPY NOTES Having evaluated an automatic thought with clients, you’ll ask them to summarize. You might pose one of the following questions: “Can you summarize what we’ve just been talking about?” “What do you think would be important for you to remember this week?” “If the situation comes up again, what do you want to tell yourself?” When clients express a strong summary, you might say, “That’s good. Would you like to write it down or would you like me to? I want to make sure you remember it this week.” You will most likely ask their preference in Sessions 1 and 2 and then assume their preference hasn’t changed unless they indicate it has. Abe and I evaluated his thought “I can’t do it” using Socratic questioning. Then I ask him to summarize. Judith: Okay, Abe, if you think about filling out the insurance forms this week and again you have the thought “I can’t do it,” what do you want to remind yourself? Abe: That it’s probably not true. My concentration was good enough to fill out a couple of job applications so I can probably at least get started on the forms. Judith: That’s good. (Writes it down.) Anything else? Abe: I could ask my son for help. Judith: (writing) That’s important too. And how about that just getting started might be the hardest part? Abe: Yeah, that’s good to remember. To make sure that what Abe writes down will be most helpful, I first ask him to express his summary verbally. This gives me a chance to add to or suggest changes to his summary. CLINICAL TIPS When clients’ responses are superficial, confused, too brief, or too wordy, you might say: “Well, I think that’s close, but I wonder if it would be more helpful to remember it this way:             .” As above, if clients’ answers are reasonable but incomplete, you might ask, “Do you also want to remind yourself that             ?” If they agree, you or they can record the addition.

Responding to Automatic Thoughts

It’s desirable for clients to read their therapy notes each morning and pull them out, as needed, during the day. They tend to integrate responses into their thinking when they have rehearsed them repeatedly. Reading notes only when encountering difficult situations is usually less effective than reading them regularly in preparation for difficult situations. Below are some of Abe’s therapy notes. They contain responses to dysfunctional thinking and behavioral Action Plans items. When I think “I’ll never get everything done,” I’ll remind myself:     I should focus on what I need to do right now.     I don’t have to do everything perfectly.     I can ask for help. It’s not a sign of weakness. Then I should figure out what’s easiest to do and set a timer for 10 minutes. At the end of 10 minutes, I can decide whether to keep going or not.

When I think “I’d rather stay inside,” I’ll tell myself that I’ve already done the experiment of staying inside lots and lots of times and my mood doesn’t get better. Chances are I’ll feel better if I do go out, to get some sun, to exercise, or to do an errand. It might feel as if I’m letting my kids down, but that’s all-or-­nothing thinking. I’m not doing as much for them physically, like helping them with yard work, as I did before I was depressed. But I’m still going to my grandchildren’s soccer games and driving them when their parents get stuck. I should call them right now and make plans to see them. Cognitive Behavior Therapy: Basics and Beyond

When I want to ask Gabe for help looking online for a new job:

1. I’ll remind myself it’s just not a big deal. The worst that’ll happen

is he’ll say he’s too busy and then I can ask Kaitlyn instead. 2. Asking him to help is an experiment. Even if it doesn’t work this

time, it’s good practice for me. 3. If he says he’s too busy, he probably really is. 4. I should call him now and ask if I can come over today or

tomorrow or vice versa.

Strategies for When I’m Anxious

1. Read my therapy notes and/or do a Testing Your Thoughts

Worksheet. 2. Call Ethan and talk about sports. 3. Accept the anxiety. I don’t like the feeling, but it’s a normal

human emotion. I can do anything with anxiety that I can do

without anxiety. It will likely decrease once I turn my attention

to something else. 4. Practice the mindfulness exercise. 5. Go for a walk. CLINICAL TIPS On a practical note, you should keep copies of your clients’ therapy notes. You can photocopy them, take a picture of them and print them out, or use carbonless copy paper. You’ll refer to these therapy notes when planning the next session (usually immediately before that session), when reviewing clients’ Action Plans, and when reinforcing ideas you had discussed with clients in prior sessions. Also, you can provide clients with a photocopy of your notes if they lose their notes.

Responding to Automatic Thoughts

Audio‑Recorded Therapy Notes Ensuring that clients have written therapy notes is ideal. They can carry around a notebook or index cards to read as needed, or they can read their therapy notes on their smartphone. But some clients can’t or don’t like to read. Or they find it’s more effective to listen to their notes. In any case, you can turn on an audio recorder or have clients use an app on their phones when developing responses to automatic thoughts; or you can note what the responses are and turn on the recorder for the last few minutes of a session, recording all responses at once. Recording and then having clients listen to an entire therapy session is often less useful. They are likely to review the recording only once during the week, instead of repeatedly listening to the most important points of the session. They may also have self-­critical thoughts as they listen. When clients aren’t literate, you can ask them how they could remember what you’ve talked about. For example, could they draw a picture? Could they get someone to read the notes to them? Could they listen to an audio recording? CLINICAL TIPS To motivate clients to read their therapy notes, use the same techniques you’d use for any Action Plan item (Chapter 8), especially linking it to their aspirations, values, and goals. Be sure to ask about obstacles that could get in the way. If they’re not sure they’ll have enough time, ask them how long they think it will take to read their notes. If they overestimate, you might ask them to read the notes aloud in session while you time them, so they can see that it actually takes a much shorter amount of time (usually 20–60 seconds). USING WORKSHEETS The Testing Your Thoughts Worksheet (Figures 15.1 and 15.2) and the Thought Record (Figures 15.3 and 15.4), also known in an earlier version as the “Daily Record of Dysfunctional Thoughts” (Beck et al., 1979), prompt clients to evaluate their automatic thoughts when they feel distressed or engage in unhelpful behavior. The worksheets elicit more information than just responding to the lists of Socratic questions in the previous chapter. It’s not necessary for clients to use these worksheets if thinking about these questions is helpful enough, but many clients find a worksheet organizes their thinking and responses better. The worksheets aren’t particularly useful for clients who are relatively low functioning, dislike writing, are unmotivated, or who have a low level of literacy. Cognitive Behavior Therapy: Basics and Beyond

Remember, thoughts may be 100% true or 0% true or somewhere in the middle. Just because you think something doesn’t necessarily mean it’s true. 1.  When you notice your mood getting worse, or you find yourself engaging in unhelpful behavior, ask yourself the questions on the reverse side of this worksheet and write down the answers. It will probably take about 5–10 minutes. 2.  Not all questions apply to all automatic thoughts. 3.  If you’d like, you can use the list below to identify cognitive distortions. You may find that more than one distortion applies. 4.  Spelling, handwriting, and grammar don’t count. 5.  It was worth doing this worksheet if your mood improves by 10% or more. Cognitive Distortions All-or-nothing thinking Example: “If I’m not a total success, I’m a failure.” Catastrophizing (fortune-telling) Example: “I’ll be so upset, I won’t be able to function at all.” Disqualifying or discounting the positive Example: “I did that project well, but that doesn’t mean I’m competent; I just got lucky.” Emotional reasoning Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.” Labeling Examples: “I’m a loser”; “He’s no good.” Magnification/ minimization Example: “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.” Mental filter Example: “Because I got one low rating on my evaluation [which also contained several high ratings], it means I’m doing a lousy job.” Mind reading Example: “He’s thinking that I don’t know the first thing about this project.” Overgeneralization Example: “Because I felt uncomfortable at the meeting, I don’t have what it takes to make friends.” Personalization Example: “The repairman was curt to me because I did something wrong.” “Should” and “must” statements Example: “It’s terrible that I made a mistake. I should always do my best.” Tunnel vision Example: “My son’s teacher can’t do anything right. He’s critical and insensitive and lousy at teaching.” FIGURE 15.1.  Testing Your Thoughts Worksheet, side 1. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania.

Responding to Automatic Thoughts

1. What is the situation? You might be having thoughts about something that just happened in the environment or something that happened inside of you (an intense emotion, a painful sensation, an image, a daydream, a flashback, or a stream of thoughts—e.g., thinking about my future). I got a parking ticket.

      2. What am I thinking or imagining? I’m so stupid.

   

          3. What is the cognitive distortion? (optional) Labeling, overgeneralizing    

          4. What makes me think the thought is true? I shouldn’t have lost track    

of time.

      5. What makes me think the thought is not true or not completely true? Other

people get parking tickets. It doesn’t necessarily mean they’re stupid.      6. What’s another way to look at this? I just made a mistake.

   

          7. If the worst happens, what could I do then? Just keep paying parking      

tickets, but it would be better to set an alarm on my phone so it    

doesn’t happen again.

      8. What’s the best that could happen? I’ll never get a parking ticket again.   

          9. What will probably happen? I could get another ticket, but I’ll probably    

remember what happened this time and make sure I don’t.     10. What will happen if I keep telling myself the same thought? I’ll keep being  

upset with myself.

    11. What could happen if I changed my thinking? I’d feel better.    

        12. What would I tell my friend or family member [think of a specific person] Gabe if this happened to him or her? It’s not that big a deal.    

So you forgot and made a mistake. You know how to avoid doing this    

in the future.

    13. What would be good to do now? Get my mind off of this. Go for a walk.   

        FIGURE 15.2.  Testing Your Thoughts Worksheet, side 2. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania. Cognitive Behavior Therapy: Basics and Beyond

3.  Then fill in the rest of the columns. You can try to identify cognitive distortions from the list below. More than one distortion may apply. Make sure to use the questions at the bottom of the worksheet to compose the adaptive response. 4.  Spelling, handwriting, and grammar don’t count. 5.  It was worth doing this worksheet if your mood improves by 10% or more. Spend just 5–10 minutes to complete the Thought Record. Note that not all questions will apply to every automatic thought. Here’s what to do. Just because you think something doesn’t necessarily mean it’s true. Catastrophizing (fortune-telling) Example: “I’ll be so upset, I won’t be able to function at all.” All-or-nothing thinking Example: “If I’m not a total success, I’m a failure.” Remember, thoughts may be 100% true or 0% true or somewhere in the middle. 1.  When you notice your mood getting worse, or you find yourself engaging in unhelpful behavior, ask yourself, “What’s going through my mind right now?” and as soon as possible, jot down the thought or mental image in the Automatic Thought(s) column. 2.  The situation may be external (something that just happened or something you just did) or internal (an intense emotion, a painful sensation, an image, daydream, flashback, or stream of thoughts—e.g., thinking about your future). Cognitive Distortions FIGURE 15.3.  Thought Record, side 1. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania. Magnification/minimization Example: “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.” Mental filter (selective abstraction) Example: “Because I got one low rating on my evaluation [which also contained several high ratings], it means I’m doing a lousy job.” Tunnel vision Example: “My son’s teacher can’t do anything right. He’s critical and insensitive and lousy at teaching.” Overgeneralization Example: “Because I felt uncomfortable at the get-together, I don’t have what it takes to make friends.” Disqualifying or discounting the positive Example: “I did that project well, but that doesn’t mean I’m competent; I just got lucky.” Emotional reasoning Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.” Personalization Example: “The repairman was curt to me because I did something wrong.” Mind reading Example: “He’s thinking that I don’t know the first thing about this project.” “Should” and “must” statements Example: “It’s terrible that I made a mistake. I should always do my best.” Labeling Examples: “I’m a loser”; “He’s no good.”

1.  How much do you now believe each automatic thought? 2.  What emotion(s) do you feel now? How intense (0%–100%) is the emotion? 3.  What would be good to do? 1.  AT (50%) 2.  Anxious (50%) 3.  Practice Date/ time Situation Automatic thought(s) Emotion(s) Adaptive response Outcome 1.  (optional) What cognitive distortion did you make? 2.  Use questions below to compose a response to the automatic thought(s). 3.  How much do you believe each response? 1.  What emotion(s) (sad/anxious/ angry, etc.) did you feel (before, during, or after the event or unhelpful behavior)? 2. How intense (0%–100%) was the emotion? 1.  What thought(s) and/or image(s) went through your mind (before, during, or after the event or unhelpful behavior)? 2.  How much did you believe the thought(s)? 6/23 Thinking about the job interview I’ll be so nervous, I won’t know what to say, and then I won’t get the job. (80%) 1.  What event (external or internal) is associated with the unpleasant emotion? Or what unhelpful behavior did you just engage in? FIGURE 15.4.  Thought Record, side 2. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Philadelphia, Pennsylvania. Questions to help compose an alternative response: (1) What is the evidence that the automatic thought is true? Not true? (2) Is there an alternative explanation? (3) If the worst happened, how could I cope? What’s the best that could happen? What’s the most realistic outcome? (4) What’s the effect of my believing the automatic thought? What could be the effect of my changing my thinking? (5) If             [person’s name] was in this situation and had this thought, what would I tell him/her? (6) What would be good to do? Anxious (75%) (Fortune-telling) I’m nervous now, but I can practice more with [my therapist]. When I was nervous in the past, like when I got a new boss, I didn’t have trouble talking. (80%) If I don’t get the job, I can apply for other ones. The best outcome would be that the interviewer will offer me the job on the spot. The most realistic outcome is that I’ll have to apply for several jobs before I get one. (90%) Thinking I won’t get the job just keeps me anxious. Realizing that it’s not the end of the world if I don’t get it makes me feel better. (100%) I’d tell Gabe that it isn’t the end of the world if he’s nervous and doesn’t get the job. But the more he practices, probably the less nervous he’ll be. (100%) I should practice what I want to say and then act as if I’m not nervous (100%)

CLINICAL TIPS Both worksheets contain similar questions, but the Testing Your Thoughts Worksheet has an easier readability level, and its more structured format is simpler and easier to complete. As you read in the previous chapter, first, you’ll identify an important automatic thought and use one of the lists of questions with the client. If the intensity of the client’s automatic thoughts and emotions decrease, you can then demonstrate how to write the answers and other information on one of the two worksheets. Note that you could pull out a worksheet immediately after identifying an important automatic thought. But if the evaluation of the thought is ineffective, clients may believe the worksheet won’t be helpful to them. In the following section, Abe and I have used the list of Socratic questions from the Testing Your Thoughts Worksheet to evaluate his thought “Gabe won’t want to go with me,” and he feels better. Next, I introduce that worksheet. Judith: Good. Now I’d like to show you a worksheet [Figures 15.1 and 15.2] that I think will help you at home. It’s called Testing Your Thoughts. It’s just an organized way of writing down what we just did. Okay? Abe: Sure. Judith: (showing it to Abe) It may take some practice for you to get really good at it. So, expect to make some mistakes along the way. These mistakes will actually be useful—­we’ll see what was confusing, so I can prepare you better the next time. Okay? Abe: Yeah. Judith: (showing side 1 to Abe) Here at the top, it reminds you that your thoughts might or might not be true. Then it tells you when to use it. (Reads aloud.) “When you notice your mood getting worse, or you find yourself engaging in unhelpful behavior, ask yourself the questions on the reverse side of this worksheet and write down the answers.” I think it’ll take you about 5 minutes to do it, maybe a little more. It also lets you know that not every question may apply, that spelling, handwriting, and grammar don’t count, that if you feel 10% better, it was worth doing, and it also lists cognitive distortions. Abe: Okay. Judith: (turning to the other side) This side is self-­explanatory. You just read a question, and if seems to apply, you write the answer next to it. Do you have any questions?

Responding to Automatic Thoughts

Abe: No, I think I understand. Judith: What do you think? Is it okay if we take another automatic thought and see if you can use the worksheet? Abe: Yeah. Make sure that clients can successfully complete one of the worksheets in session before you suggest it as an Action Plan assignment. For some clients, it’s better to introduce the Thought Record in two stages. In one session, you might teach clients to fill in the first four columns and ask them to do the same at home when they’re feeling upset. If it goes well, you can then teach them to use the final two columns at the following session. WHEN A WORKSHEET ISN’T HELPFUL ENOUGH As with any technique in CBT, it’s important not to overemphasize the importance of worksheets. Most clients, at some point, find that completing a particular worksheet did not provide much relief. If you emphasize its general usefulness and “stuck points” as an opportunity for learning, you help clients avoid automatic thoughts critical of themselves, the therapy, the worksheet, or you. As described in the previous chapter, evaluation of an automatic thought (with or without a worksheet) may be less than optimal if clients fail to respond to their most upsetting thoughts or images, if their automatic thought is a core belief, if their evaluation and response are superficial, if they discount their response, or if the automatic thought is part of a dysfunctional thought process. CLINICAL TIPS If you’re not highly confident that clients will be able to use a list of questions or a worksheet effectively at home, ask them to predict what might happen. Judith: If you have trouble evaluating your thoughts this week, how are you likely to feel? Maria: Frustrated, I guess. Judith: What’s likely to go through your mind? Maria: I don’t know. I’ll probably just quit. Judith: Can you imagine looking at the sheet of paper and not being able to figure out what to do? Cognitive Behavior Therapy: Basics and Beyond

Maria: Yeah. Judith: What’s going through your mind as you look at the paper? Maria: “I should be able to do this. I’m so stupid.” Judith: It’s good you told me that. Do you think it would help to have a reminder that it’s just a skill you’ll get better at? And that I can help you at the next session? Maria: Yes. (Records it in the therapy notes.) Judith: Do you think this response will help enough? Or do you think we should put off this Action Plan item until we have more time to practice together? Maria: No, I think I can try it. Judith: Okay, now if you do get frustrated and have automatic thoughts, be sure to jot them down. Okay? Here I make the Action Plan into a no-lose proposition: Either Maria does it successfully, or we’ll collaboratively work on it at the next session. If frustrated, she either reads her therapy notes (and probably feels better) or keeps track of her thoughts so we can address them together.

Finally, as described in the previous chapter (p. 256), clients may be able to take a shortcut without the structure of a list of Socratic questions or a worksheet—­but be careful that their responses aren’t superficial. You can use two formats. One, described on pages 256– 257, takes the following form: “When I think             , I should remind myself             .” Another form is the two-­column technique (automatic thoughts and responses), shown below.

Automatic thought Response “I want to skip the reunion.” “It’s better for me to go. I could reconnect with people. And someone might have a lead for a job.” “If I tell Rita I don’t want to change the holiday plan, she’ll get angry.” “If this doesn’t get her angry, something else will. I should do what’s good for me—not accommodate her all the time.”

Responding to Automatic Thoughts

SUMMARY There are two major ways that clients respond to their unhelpful thinking between sessions. They can read their therapy notes, if you’ve previously evaluated the thought with them in session. Or they can use a list of Socratic questions or a worksheet to evaluate new automatic thoughts. It’s better to use the questions on a worksheet verbally with clients. If you successfully help clients evaluate an automatic thought, then you can show them how to use a worksheet that contains the same questions. When a worksheet isn’t sufficiently helpful, conceptualize the difficulty so you’ll know what to do. REFLECTION QUES TIONS What problems could arise in introducing a worksheet to a client? What can you do when a worksheet isn’t helpful enough? How can you reduce the likelihood that clients might become self-­critical if they can’t successfully complete a worksheet? PRACTICE EXERCISE Identify an automatic thought that could interfere with your doing a Thought Record yourself. Then evaluate and respond to this thought using a Thought Record. Next, identify one of your dysfunctional thoughts about any situation, and use the Testing Your Thoughts Worksheet. Also, do a role play in which you introduce a client to one of the worksheets. Remember, start by helping the client successfully evaluate an automatic thought verbally, using the questions on the worksheet. Then pull out the worksheet and show the client how to fill it in. Cognitive Behavior Therapy: Basics and Beyond