Testing Negative Automatic Thoughts by hcj

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									   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
    - 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


                      Other aspects of functioning/ symptoms
                Emotional state, behaviour, coping strategies, bodily state
Presenting the rationale for identifying NATs
Distressed response             Response learned in CT



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
   How could you overcome these blocks? Try
    to come up with specific and concrete
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
   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,
   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:

  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
   Guiding discovery rather than changing minds (Padesky,
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

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
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

   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
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

   In pairs, each person to take turn as therapist and
   Therapist to enquire about a recent example –
    situation, emotion and cognitions
   Use downward arrow questions to clarify the
    cognitions your client reports

   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
   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

   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
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-

-   “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”
   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”

   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
    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
   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
   Are there any small things that may contradict my
    thoughts that I may be discounting as not
   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
   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
     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
Feedback from evaluating NATs
   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
   Unhelpful thinking processes include thought
    suppression, rumination and worry, and
    meta-cognitive concerns (+ and -)
    identified as transdiagnostic problems (Harvey et al.,
   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
    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
   „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
    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

   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

       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
    Across a range of disorders there seems to be
     little difference between CT, BT and CBT
    Limited evidence that cognitive change mediates
    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
   Westbrook, D., Kennerley, H., and Kirk, J. (2007). An
    introduction to cognitive behavioural therapy: Skills
    and applications. London: Sage.

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