Skills in Cognitive Behaviour Counselling and Psychotherapy CHAPTER 4: Skills for working with negative thoughts

1. Skills in Cognitive Behaviour Counselling and PsychotherapyCHAPTER 4: Skills for working with negative thoughts FRANK WILLS (2008) London: SAGE

2. Cognitive therapy: a fast moving and developing field • It is sometimes wrongly read back into the early models of CT that they recommended overcoming emotion by changing thoughts. If it ever was meant to be read in that way, it is not now the case. • Firstly, it is important to honour emotion - even when it is painful it is telling something. That something may become clearer if we are able to review the emotion with reason. • Secondly, the content of thinking is only half the story. It turns out that we all have negative thoughts, but that some of us sometimes pay particular attention to those thoughts in ways that may cause us greater problems. This tells us that cognitive processes and cognitive content both play a role in psychological problems. Both therefore need to be addressed.

3. Why cognitive techniques work • Optimal functioning seems best promoted when ‘heart and head’ work in fine-tuned cooperation. • When ‘head’ is over-dominant, we may become ‘intellectualisers’, out of touch with feeling. • When ‘heart’ is over-dominant, we may become ‘emoters’, subject to ‘emotional reasoning’. • Balance may be restored by considering both ‘propositional’ and ‘implication’ factors (Teasdale, 2004) and ‘rational’ and ‘experiential’ factors (Epstein, 1998). • Negative emotion may overwhelm rational capacity so that rational capacity may need support from supplementary cognitive steps, such as using a thought record or applying ‘cognitive reframing’ techniques.

4. Stages in working with negative thoughts: 1: Identifying negative thoughts • Combine knowledge from CBT research about ‘cognitive specificity’ (e.g., specifically depressogenic thoughts, anxiogenic thoughts etc.) with the knowledge of the client’s individual and idiosyncratic thought patterns. • Also watch out for ‘cognitive distortions’ – most commonly occurring are: APPLYING A NEGATIVE LABEL; MAKING NEGATIVE PREDICTIONS; and OVER-STATEMENTS.

5. SOCRATIC QUESTIONING AND GUIDED DISCOVERY • Socrates ‘baffled’ people who debated with him. He tended to lead them to ‘aporia’ and ‘not knowing’- a gap in their knowledge. • It is helpful to get comfortable with not knowing - it leaves a space for new possibilities. • SQ/GD is not persuasion. Persuasion is often counter-productive (Heesacker & Meija-Millan, 1996). • SQ/GD is achieved by well-sequenced and telling questions – see next slide.

6. Padesky’s four-stage sequence of guided discovery • Ask questions to uncover information outside client’s current awareness. • Accurate listening and empathic reflection. • Frequent summaries. • Ask synthesising questions that help to apply new information to the client’s original thought.

7. 2: Evaluating negative thoughts • Watch out for specific cognitive themes (e.g, anger = transgression); cognitive distortions and cognitive biases (‘limited search routines). • Strive to link salient thoughts to salient emotions. Not any old thought will do - find the ‘hot thought’: Beck ‘Emotion is where the action is.’ Emotions can be intensified by using ‘first-person, present-tense’ language when reviewing trigger situations.

8. Helpful dimensions to test when evaluating negative thoughts • Emotional intensity – use belief and emotion ratings • Ratings give the meta-message that thoughts and emotions are not immutable – indeed they vary over time. • How valid are the thoughts – would they ‘stand up in court’? • What is the scope of the thoughts? (e.g., ‘I am crap’ implies that all of me is crap.) • Albert Ellis was right to point out that (until you are dead) all the results are not yet in. We can almost always fairly say, ‘I demand a recount!’

9. Seven-Column Thought Record

10. Guidelines for working with thought records • Thought records tend to work when they are specific, focused and precise. • TRIGGER: Go for a specific moment in time, ask; ‘When did the bad feeling kick in?’ • EMOTIONS: Go for sharp primary emotions, ‘fearful’ ‘low’ etc., rather than thoughts dressed up as emotions, e.g., ‘I felt like no one was listening to me.’ • NATS/IMAGES: Seek out the appraisal and meaning underneath the thought. It may be better seen in images. • EVIDENCE: Test that evidence is credible to the client • OUTCOME: Don’t forget behavioural outcome – ‘So next time I will …’

11. Problems with thought records • Thought records, like true love, do not run smooth. • Can be time-consuming –best done close to time done if possible. Think of developing a ‘top-pocket’ version, BUT discuss client’s need to keep them private. • Some triggers – illness – seem unreservedly negative. • Some evidence seems to weigh more than other evidence. • Sometimes intellectual conviction does not breed emotional conviction. • GENERALLY these problems can be overcome with persistence. Problems have built up over a long time and will not disappear quickly. Negative thoughts work by a drip–drip effect, and so probably do thought records. Thought records should be part of a mixed strategy so that the focus can be shifted to other interventions – e.g., behavioural experiments if problems persist.

12. Working with attention and other cognitive processes • It has been increasingly realised that certain problems evolve because of the way clients pay attention to negative thoughts rather than because of the thoughts themselves. • It seems, for example, that nearly everyone has OCD thoughts at times but sufferers get stuck with them because they do not seem to be able to let then go, as non-sufferers do. Wells (1997, 2000) has suggested that part of the treatment for OCD (and GAD worry) should include helping clients to learn how to regard intrusive thoughts with ‘mindful detachment’. • Although these ideas seem to relate to new CBT developments such as mindfulness and ‘acceptance and commitment therapy (ACT)’ they are also somewhat evident in Beck’s earlier idea (see next slide). Interestingly, Beck is a regular meditator and has conducted a recent dialogue with the Dalai Lama.

13. AWARE STRATEGY FOR DEALING WITH ANXIETY (Beck & Emery, 1985) Abridged • ACCEPT your anxiety … agree to receive it… welcome it… say ‘hello’… don’t fight it … by fighting it, you prolong it…. • WATCH your anxiety … look at it without judgement … not good, not bad … watch it go up and down. • ACT with the anxiety … function with it … slow down if you have to, but keep going. • REPEAT the steps (1–3), continue to accept, watch and act with it. • EXPECT the best. What you most fear rarely happens ….

14. THE WORRY CURE(Robert Leahy, 2005) 1. Distinguish between productive and unproductive worry. 2. Accept reality and commit to change. 3. Challenge worried thinking. 4. Focus on the deeper threat. 5. Turn failure into opportunity. 6. Use emotions rather than worry about them. 7. Take control of time.