Testing Negative Automatic Thoughts 28 January 2010 Tracy Chotoo and Rita Woo Workshop Aims Understanding difficulties in identifying NATs Developing an alternative perspective to NATs - Socratic questioning and guided discovery - Consideration of the content and process of automatic thoughts The cognitive model of emotional disorders reviewed (Early) experiences Events, relationships, social and cultural circumstances Core beliefs/ absolute assumptions Conclusions drawn about the self, world, others etc. in light of experience (I am…., the world is…., Others are…. Etc.) Conditional assumptions and rules Guidelines for living, standards, rules, which evolve from core beliefs (e.g. to compensate) Contain moral, religious, cultural and social influences (If….then…., Should or Must statements, Value judgements) Critical incident(s) Events which impact on (e.g. activate/ shatter) pre-existing beliefs and assumptions Activation of negative beliefs and assumptions Negative automatic thoughts Thoughts, images, meanings enter consciousness Rapid, fleeting, generated by assumptions and beliefs in response to specific situations Maintenance Other aspects of functioning/ symptoms Emotional state, behaviour, coping strategies, bodily state Presenting the rationale for identifying NATs Distressed response Response learned in CT Situation NATs Aha!! Affect, behaviour, (understanding the patterns/ Bodily reactions etc sequences so far) search for alternatives Reduce distress Coping/ adaptive behaviour Homework Review: NAT Diaries (groups of 4) How did you get on? Were you able to identify NATs? What was it like recording these thoughts? What did you learn about the process? If you did not do the homework, or encountered difficulties, what were the blocks? How could you overcome these blocks? Try to come up with specific and concrete strategies Large Group Discussion How might doing this exercise help you when working with clients? What stumbling blocks or problems are you aware of, and how might you prevent problems arising, or overcome them? What differences might there be for someone who is anxious or depressed? What are the pros and cons of identifying NATs for clients? Review - Common Difficulties Identifying NATs – (see Westbrook et al, ‟07; Sanders and Wills) The client avoids thoughts – focuses on feelings The client has difficulty identifying or labeling emotions (e.g. “I felt uncomfortable") Client intellectualizes responses and avoids emotions The client‟s thoughts are fleeting – meant to write them down and then forget (Westbrook et al., 2007) The client is avoiding triggers Common Difficulties Identifying NATs II The client writes pages and pages of thoughts and musings Superficial thoughts provided The client avoids discussing upsetting situations (Moore and Garland, 2003) Patient fears therapist responses Thoughts and feelings don‟t match– client reports a panic attack but described thoughts such as “It‟s going to be OK” Socratic Questioning “The goal of cognitive therapy is not simply to make our clients think differently or feel better today. Our goal as cognitive therapists is to teach our clients a process of evaluating their goals, thoughts, behaviours and mood so that they can learn methods for improving their lives for many years to come” (Padesky, 1993). Socratic Questioning – (see Kennerley, 2007; Padesky, 1993a; Westbrook et al., 2007) “The cornerstone of cognitive therapy” (Padesky, 1993a) Socrates - would encourage young Athenians to discover answers for themselves through a process of guided discovery Open ended questions about the client‟s internal and external world, which they have the knowledge to answer Premise that answers have more emotional salience if they are discovered by the client, rather than told Socratic Questioning can be helpful in: 1.Assessment Identifying cognitions, affect, behaviours 2. Formulation Exploring connections, consequences, patterns Checking out therapist’s hypotheses 3. Challenging unhelpful cognitions Looking for evidence for and against Generating alternative ways of looking at things 4. Problem solving and arriving at solutions Considering options, pros and cons, possibilities 5. Devising behavioural experiments Working out ways of testing beliefs /assumptions Socratic Questioning: Key features – I You have asked a good Socratic question if: The client can work out the answer to it It reveals new perspectives Assumes the client knows the answers and therapist is expert at helping them discover Draws attention to information and solutions relevant to the problem, which may have been outside the client‟s awareness Guiding discovery rather than changing minds (Padesky, 1993a) Socratic Questioning this consists of asking the client questions which: 1. S/he has the knowledge to answer 2. draw the client‟s attention to information relevant to the issue under discussion but outside her/ his current focus, i.e. widens their perspective 3. move from the concrete to more abstract so that the patient can apply the new information to re-evaluate a previous assumption or belief or construct a new one Socratic Questioning Not positive thinking Not a case of the therapist persuading the client to see things from his/her point of view. The goal is balanced and realistic thoughts The question “What do you mean when you say x?” can help to clarify idiosyncratic meanings Try to avoid too many “why...” questions. Alternatives include “what are some of the reasons you think...” “in what ways do you believe…” Socratic Questioning Brewin (2006):“CBT does not directly modify information in memory, but produces changes in the relative activation of positive and negative representations such that the positive ones are assisted to win the retrieval competition” DTRs may help people to create new representations in which –ve thoughts are associated with more positive mood, positive memories, and realistic standards In order for alternatives to enjoy retrieval advantage over original thoughts important to ensure that no stone is left unturned. Otherwise negative self-representations may still be triggered by specific triggers The 4 elements of Socratic questioning (see Padesky, 1993a) 1. Ask concrete, informational questions 2. Empathic listening 3. Frequent summaries – check and clarify what has been said. Give yourself time to think 4. Synthesising questions So, how does this information fit together? What sense do you make of that? How might these ideas make a difference to you? - What would your close friends say if they knew all this? - Given what you have been telling me, what do you think will help? Key Questions to facilitate the Socratic Method – gathering information What do you think/ feel about that? What is going/ went through your mind? What does that mean to you/ say about you/ others/ the world? If that were true, what would that mean to you? What’s the worst that could happen? Downward arrow technique (see Leahy, 2003, Westbrook et al, 2007) Technique designed to help clients unpack or further analyse the meaning of unhelpful cognitions Can help identify client‟s fundamental belief system – the “bottom line” (Fennell, 1999) or “bottom triangle” (Westbrook et al, 2007) Beware „psycho-bulldozing‟ (Westbrook et al., 2007) “Is it alright for me to continue with these questions?” “Do you need a bit of a break?” Tone is very important Model the compassionate voice “This may sound like a silly question, but….” Try not to plough straight in with too much disputation Death may not be the bottom – beware premature ending Downward arrow – an example T – What was going through your mind before going to the party? P – I‟ll become anxious before talking to people T – And if you did feel anxious, what could happen? P – People wouldn‟t want to talk to me T – And what would that mean? P – That I‟m not worth talking to T – What sort of a person is not worth talking to? P – A loser T – If you‟re a loser then that means….? P – I‟ll never find anybody T – And if that were to happen? P – I‟ll always be alone and miserable Downward arrow: some helpful questions (see Burns, 1989; Leahy, 2003; Westbrook, 2007) I wonder what seems so bad about that? In your view, what does that mean? What does that say about you / others / the world? What would that mean about your life / your future? What would others think of you? How would you label that? Can you describe the worst that could happen? If that was true… Exercise in pairs: Downward arrow technique In pairs, each person to take turn as therapist and client Therapist to enquire about a recent example – situation, emotion and cognitions Use downward arrow questions to clarify the cognitions your client reports Reflection As a client, what was helpful about being asked these questions? Anything that you found difficult (be specific)? As a therapist, what was useful / more difficult? What was this like when working with someone who is depressed / anxious? What do you feel you need to work on? Role play: in pairs, 20 mins each Use Socratic questioning to ask the “client” about their current problems (see cases) Ask about the triggering situation, thoughts, feelings, & coping, map out the vicious cycles Try to identify key NATs and emotions, and ask about intensity/ belief ratings from 0-100% Use regular summaries and feedback Encourage client to write this information on a thought diary (columns 1-3) (will be used again later) Role play: Feedback Were you able to identify key feelings, thoughts and behaviours? What was it like to use Socratic questioning as the therapist? What difficulties, if any, arose? What did it feel like to be asked about your problem in this way as a client? Were there differences between depressed and anxious clients? What difficulties might arise with when identifying NATs and how can you deal with them? Exploring the Content of Thoughts Appraising / Evaluating NATs Key aim decentring from thoughts : “thoughts as mental events rather than expressions of reality” (Beck 1979) Socratic questioning is the key cognitive technique in-session –guided discovery vs. changing minds! Evaluating NATs: how to do it Identify situation, expand and clarify thoughts and feelings – “it‟s no wonder….” “I can understand why…” Target “hot” thoughts that have high affect. Develop awareness of cognitive biases Explore evidence for and against the NAT (current and historical), then develop positive alternatives Highlight any recurrent thought biases Use NAT diary additional columns to summarise, and generate new perspective Aim is to reduce belief rating (0-100%) in original NAT, and associated negative affect - need to be re-rated Identifying cognitive biases (see attached handout for examples) Info-processing biases – normal and necessary heuristics to process incoming stimuli Exaggerations in information processing style – likely to be more pronounced when affect is high Can be problematic when bias is too extreme Awareness of info-processing style can be a step towards decentring from thoughts - rather than focusing on content. Aim is to identify information processing biases – can open way to considering alternative views Socratic Questions and appraising NATs - “Consequence of” questions: Can elicit pros and cons of current beliefs and act as a motivation to re- evaluate - “Evidence for” questions: validating the client‟s current reality –developing a “balanced view”; helps understand why thoughts may have developed - “Evidence against” questions: directing attention to experiences / incidents that challenge the orig. belief – can undermine their validity - “Alternative view” questions – re-evaluating things in light of all of the evidence, developing a new conclusion / perspective Socratic Questions: “consequence of” NATs How helpful or unhelpful is it to hold this particular belief? (Elicit in detail) What for you are the advantages of seeing things this way? Are there any disadvantages for you in seeing things this way? (Consider both short and longer term) If you see the world this way, how do you feel and behave? How do others react? Socratic Questions: “Evidence for” NATs In your experience, what fits with this belief, what makes it seem true? When you think X, what evidence do you have that supports this thought? Why might any of us have that thought at some time? Key Socratic Questions for Appraising NATs (see Greenberger and Padesky, 2005) Have I had any experiences that show that this thought is not true all the time? Is there anything that doesn’t seem to fit with this thought? If a friend or someone I love had this thought, what would I tell them? If a friend or someone I love knew that I was having this thought, what would they say to me? What evidence would they point out that my thoughts are not true 100% of the time? When I am not feeling this way, how do I view this type of situation? When I have felt this way in the past, what did I think about to help myself feel better? If you fast-forwarded 5 years from now, how would you view this situation? Socratic Questions for Appraising NATs (Greenberger and Padesky, 2005) Have I been in this type of situation before? What happened? Is there anything I learned from my past experiences that I could use in this situation? Are there any small things that may contradict my thoughts that I may be discounting as not important? Are there any strengths or positives in me that I am ignoring? Am I blaming myself for something over which I do not have complete control? Am I jumping to conclusions? Socratic Questions: Developing an alternative / balanced view (Greenberger and Padesky, 2005) Based on the evidence listed, how would you now view your original concern? If someone I cared about was in this situation and had these thoughts, what would be my advice to them? How would I suggest they understand the situation? If my hot thought is true, what is the worst outcome? What is the best outcome? What is the most realistic outcome? Given what you have just described, how likely is it that the worst will happen? If it did happen, what could I do to cope? Can someone I trust think of another way of understanding the situation? Socratic questions and problem solving Define and identify the problem (clear and specific). Generate alternative solutions: “How would a (respected) friend deal with this dilemma?” “Given that you have identified X as an obstacle to Y, how would you advise a friend to start to resolve this?” “what are some possible ways of managing this problem?” Evaluate each solution: “What are the advantages and disadvantages of that approach?” “What might go well if you tried this?/ What might be difficult?” “What would be the worst-case scenario if that solution didn’t work?” How could you prepare for that? What could you do if it did happen? PADESKY VIDEO challenging/ restructuring negative automatic thoughts Role play: in pairs, 25 mins each way Use Socratic questioning to challenge the “hot” NATs identified in the last role play Use the DTR columns to record evidence for and against the thoughts Be gentle but persistent – “Is there anything else that makes you think X?...” Re-rate intensity scores for belief in the NAT and emotional intensity (0-100%) at the end of the exercise Feedback from evaluating NATs exercise Were you able to change the belief and emotional intensity ratings? What was it like to use Socratic questioning to challenge NATs as the therapist? What did it feel like as a client? Was it helpful? What difficulties might arise in therapy and how can you deal with them? Appraising NATs – testing out new conclusions Collaborative Empiricism – thoughts as hypotheses to tested, data collected to generate new information and/or evaluate beliefs, developing new beliefs Learning theory suggests that we absorb information most effectively if thinking is linked with action Research – CBT interventions more effective when combine both cognitive and behavioural change (Bennett-Levy): consolidate learning, and generalise from treatment everyday life Discussion – in pairs What sorts of things could your client (from role play) think about doing to check out the new perspective they have developed? Working on the Process of Thinking As well as working with the content of thoughts it may also be helpful to work on the process Unhelpful thinking processes include thought suppression, rumination and worry, and meta-cognitive concerns (+ and -) identified as transdiagnostic problems (Harvey et al., 2004) CBT intervention would focus on the process, rather than specific content Further Cognitive Techniques (see Leahy 2007) Cost-benefit analyses / advantages-disadvantages Useful as a motivational technique Short-term vs. long term Pie charts (see Greenberger & Padesky / Leahy) Good for exploring a range of alternative perspectives Aim of reducing probability estimates for catastrophic outcomes Particularly useful for guilt and anxiety problems Step 1: Belief rating in target thought (%) Step 2: Develop list of alternative explanations (incl rating) Step 3: Fill out the pie, starting with the most benign explanation Step 4: Review pie, reappraise original belief rating NATs: using imagery and role play Imaginal rehearsal – imagining self coping in a problematic situation Transforming problem images: - developing a more positive ending - manipulating distressing images - updating problem images in PTSD (see Grey, Young and Holmes, 2002) Constructing an image of how client would like things to be - can help clarify the thoughts and behaviours associated with this way of being (Padesky & Mooney, 2005) Role play - testing out new skills in safer context Compassionate mind development ( - see Gilbert 2005) Appraising NATs – common problems Client cannot label emotions Client cannot identify thoughts Avoidance (affective or cognitive) Client does not think it will be helpful Client is scared that they will feel worse if they focus on thoughts/ feelings Aimless / meandering questions There is no affective and/ or cognitive change after challenging the NAT Appraising NATs – common problems Does the client understand and accept the CBT model? Are they motivated to change? Has a specific situation been described? Has mood/ thought been clearly identified? Is NAT being tested “hot”/ central for the client? Are there multiple hot thoughts? Is there an even hotter thought? Check with the client. Has all the evidence for/ against the thought been identified and challenged? Is the alternative believable/ testable? Is the NAT a core belief too? Addressing difficulties: Points to consider „Golden rule‟ - go back to the formulation – does this predict any specific problems that might arise? E.g. Avoidance, shame, skills deficits, core beliefs Does the client require further psychoeducation about thoughts/ feelings and usefulness of focusing on them in therapy? Addressing difficulties Use the downward arrow to identify and challenge metacognitions e.g. “if I focus on my thoughts I will go mad” or “if I tell my thoughts to my therapist they will think I am stupid” Consider the therapeutic alliance – does the client feel safe to disclose and challenge thoughts in the session? What if the NAT is/ might be true? Cost benefit analysis of thinking this way Cognitive problem solving skills Discriminate unpleasant emotion Identify trigger (internal or external) Identify NATs accompanying emotion Search for more realistic/ helpful alternatives Generate solutions/ coping strategies Test out in action (behavioural experiments) Reinforce changes in thinking by assessing outcome of action (or return to 4) Common problems with Socratic Questioning – challenges for the therapist (Westbrook et al., 2007) Aimless, meandering questions Remember to ask questions pertinent to the formulation Keep questions short, written summaries, tape sessions Lecturing Self reflection, listen to tapes Acknowledge and work on problems in the relationship Exploration but no synthesis Remember to synthesize information with accurate summaries that can be linked to the formulation Language/comprehension/memory problems Yes, but.... Do we need to challenge thoughts? (Longmore and Worrell., 2007) Component analysis suggests no additional benefit of adding cognitive to behavioural techniques Across a range of disorders there seems to be little difference between CT, BT and CBT Limited evidence that cognitive change mediates outcome Different interventions may help people to switch modes or schematic models. Modes/schematic models contain multiple representational elements. Targeting one aspect of a system may lead to change in the others. Reflective Practice – groups of 4 What have you learned about identifying and challenging NATs From the client‟s point of view As a therapist How will this impact on your practice? What do you need to do to develop these skills further? Recommended Reading Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Kennerley, H. (2007). Socratic Method. Booklet available from the Oxford Cognitive Therapy Centre - www.octc.co.uk Leahy, R.L. (2003). Cognitive therapy techniques: A practitioners guide. New York, Guildford. *Padesky, C.A. (1993a). Socratic questioning: Changing minds or guiding discovery? Keynote address delivered at the European Congress of Behavioural and Cognitive Therapies, London. See www.padesky.com Westbrook, D., Kennerley, H., and Kirk, J. (2007). An introduction to cognitive behavioural therapy: Skills and applications. London: Sage.
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