How to evaluate automatic thoughts? - Chapter 14

This chapter discusses way to evaluate automatic thoughts.

What are some ways to address the thoughts a client has?

Clients can have a thousand thoughts a day. In therapy there is no time to evaluate them all, and you will only address a few of them per session. Selecting key automatic thoughts is paramount to addressing them. To determine if an automatic thought is an important one the therapist needs to answer the following questions: Is the automatic thought (still currently) distressing to the client? Is the client likely to have this kind of thought again? There may also be situations in which an automatic thought seems to be important, but the therapist will decide not to discuss it. For example a reason could be that there is an even more important problem to discuss or that the client’s level of distress is too high to evaluate his thinking.

Another method is to use Socratic questioning. When an important automatic thought is identified, the therapist should collaboratively decide with the client to evaluate it. The automatic thought should not be directly challenged, because as a therapist you don’t know if an automatic thought is true, a direct challenge may lead clients to feel invalidated and challenging a cognition violates a fundamental principal of CBT, that of collaborative empiricism: the client should get the chance to test the automatic thought’s validity. Socratic questions help clients evaluate their thinking and involve a dialectical discussion. In CBT this dialectical discussion needs to be structured in order to discuss the thoughts in depth. There a different kinds of questions that can be asked in evaluating an automatic thought:

• The ‘evidence’ questions. Because automatic thoughts usually contain a degree of truth, clients usually do have some evidence that supports their accuracy, but they often fail to recognize evidence to the contrary:

  • For example: "What is the evidence that supports this idea?"

• The ‘alternative explanation’ question:

  • For example: "Is there an alternative explanation or viewpoint?"

What other sorts of questions could be asked in order to address a client's issues?

In addition to the aforementioned, there are specific categories of questions that could be used to help a client assess their automatic thoughts. A few examples are:

• The ‘decatastrophizing’ questions:

  • Many clients predict a worst-case scenario, but that almost never happens. The therapist can lead them to realizing that and help them think of more realistic outcomes. The therapist can also let the client see that even if the worst would happen; the client would be able to cope. For example: "What is the worst that could happen?"

• The ‘impact of automatic thought’ questions:

  • The therapist helps the client assess the consequences of responding and not responding to his/her distorted thinking. For example: "What could be the effect of changing my thinking?"

• The ‘distancing’ questions:

  • Clients often benefit from getting some distance from their thoughts by imagining what they would tell a close friend or family member in a similar situation. For example: "What would I tell a friend if he or she was in my situation?"

• The ‘problem solving’ questions:

  • The therapist and client think of ways to solve the problem and come up with a behavioral plan. For example: "What should I do?" The therapist helps the client devise an alternative explanation for what has happened.

Asking all of these questions takes too long and might make the process too burdensome for a client. Therefore the therapist should choose one or two that they think are most relevant. The process will get shorter the longer the client already is in therapy. The client will eventually know what is expected of them and will only need minor encouragements from the therapist.

What are some follow-up steps a therapist should take?

Therapists need to assess the outcome of the evaluation process. In this phase the therapist checks how much the client still believes the automatic thought. In addition, they also need to conceptualize when evaluation is ineffective. If the client still believes the automatic thought, the therapist needs to conceptualize why the cognitive restructuring has not been sufficiently effective. Reasons why the restructuring might have been ineffective could be that: there are other more central automatic thoughts left unevaluated, the evaluation of the automatic thought is superficial or inadequate, the client has not sufficiently expressed the evidence that he or she believes supports the automatic thought, the automatic thought itself is also a core belief or the client understands intellectually that the automatic thought is distorted, but does not believe it on an emotional level.

Some other methods may be to use alternate methods of questioning and responding to automatic thoughts.

In addition to using Socratic questions you could also:

• Vary the questions.

• Identify the cognitive distortion. Clients tend to make consistent errors in their thinking. Often there is a systematic negative bias in the cognitive processing of clients who suffer from a psychiatric disorder. The most common errors are:

  • All or nothing thinking: clients view a situation in only two categories instead of on a continuum.

  • Catastrophizing: clients predict the future negatively without considering other, more likely outcomes.

  • Disqualifying or discounting the positive: clients unreasonably tell themselves that positive experiences, deeds, or qualities do not count.

  • Emotional reasoning: clients think something must be true, because they feel it so strongly.

  • Labeling: clients put a fixed, global label on themself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.

  • Magnification/minimization: When clients evaluate themselves, another person, or a situation, they unreasonably magnify the negative and minimize the positive.

  • Mental filter: clients pay too much attention to one negative detail instead of seeing the whole picture.

  • Mind reading: clients believe they know what others are thinking, failing to consider more likely possibilities.

  • Overgeneralization: clients make a sweeping negative conclusion that goes far beyond the current situation.

  • Personalization: clients believe others are behaving negatively, because of them, without considering more plausible explanations for their behavior.

  • ‘Should’ and ‘must’ statements: clients have a fixed idea of how they or others should behave, and they overestimate how bad it is if these expectations are not met.

  • Tunnel vision: clients only see the negative aspects of a situation.

• It often helps to label distortions and to teach clients to do the same. A therapist may also provide clients with a list of all the distortions.

• Use self-disclosure. The therapist tells the client a relevant example of his/her own life to show the client that the therapist also sometimes had those thoughts and was able to change them.

• Respond when automatic thoughts are true. When automatic thoughts are true the therapist should focus on problem solving, investigate whether the c;ient has drawn a valid conclusion, or work on acceptance of the problem.

• Teach clients to evaluate their automatic thoughts. This will take place at the end of therapy, when clients know what is expected of them.