Slide 46. Slide 47. Slide 48. Automatic Thoughts: Challenges. Working with Automatic Thoughts in Session

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1 Slide 46 Working with Automatic Thoughts in Session Always ask: What was going through your mind when: A problem situation is described that happened between sessions There is strong emotion in a session Hot cognitions: Important AT s that are experienced during the session that have to do with their performance in the session, the work in the session OR with the therapeutic rapport (watch for affect shifts) Which are the most distressing thoughts: before, during, or after Slide 47 Difficulties with Automatic Thoughts: I don t know Ask about feelings and where they experience it in their bodies Get details about the problem situation Have them visualize the situation Role play the situation with you Elicit an image Use opposite thoughts to hypothesized AT s Ask about their sense of the situation s meaning Phrase the questions differently Slide 48 Automatic Thoughts: Challenges Automatic Thoughts versus Interpretations Automatic Thoughts versus Embedded Expressions Changing from Telegraphic/Question Thoughts Recognizing Situations

2 Slide 49 Other ways to Ask about AT s What do you guess your thoughts were? Therapist provides a couple of possible thoughts: Do you think you were thinking about - -- or ----? Were you having a memory about something that happened before or something you thought might happen in the future? What the this situation mean to you/say about you? Therapist provides opposite thought to hypothesis: Were you thinking about----? Slide 50 Automatic Thoughts: Activity Pair up with a colleague take notes Each take turns eliciting AT s from a recent event that caused strong emotion Ask: What was going through your mind Ask if there were other thoughts that went through their mind Determine the type of AT with validity and utility Determine if there were any Hot Cognitions Determine which thoughts were most distressing: before, during, or after Slide 51 CBT Identifying Emotions Work with emotions that cause high distress: Interfere with clear thinking Impair problem solving Block effective actions, and Decrease satisfaction Seek to increase positive emotions: Interests Events Memories

3 Slide 52 CBT-Emotions Task List Distinguish emotions from automatic thoughts Increase emotion discrimination Label emotions increase emotion vocabulary Scale the intensity of emotions Slide 53 Emotions Identification Activity Pair up with a colleague take notes Choose a different situation from your list Help the Client determine at least two AT s Help the Client decide on emotions as a result of the AT s Scale the emotions 1-10 Slide 54 Evaluating Automatic Thoughts Selecting important AT s Using Socratic Questioning Evaluating the outcomes of the process When evaluation is ineffective Alternative questioning options When automatic thoughts are true Patient self-evaluation of AT s

4 Slide 55 Important Automatic Thoughts Current distress Likely to recur What was the situation connected to the AT? How much did you believe it at the time? Now? What was your emotion? How intense then? Now? What was your reaction? (Action/Behavior) What else went through your mind? Thoughts? Images? Which thought/image caused the most distress?** Slide 56 Socratic Questioning Problems with directly challenging an AT Invalidation Distortion level can not be determined by therapist Decreases collaboration if you tell them Socratic Questioning Goals: Determine validity Explore viewpoints and interpretations Decatastrophize the situation Recognize the impact of believing the AT Create distance with AT Begin problem solving Slide 57 Types of Socratic Questions Evidence Alternative Explanation Decatastrophizing Impact of the AT Distancing Problem-solving

5 Slide 58 Socratic Questioning Activity Pair up with a colleague take notes Determine AT s with another situation Use at least two categories of Socratic Evidence (For? Against?) Alternative Explanation (for the AT) Decatastrophizing (Worst? Cope? Best? Realistic?) Impact of the AT (Effect of believing? Impact of changing?) Distancing (What would you tell someone else?) Problem-solving (What could you do?) Slide 59 Other ways to Evaluate the AT Notice when the AT is also a core belief Be aware when the patient understands intellectually but has not translated it emotionally Identifying the cognitive distortion When the AT is true: Problem Solve Seek acceptance Investigate any invalid or dysfunctional conclusions Slide 60 Basic Cognitive Distortions All or Nothing Thinking Catastrophizing Disqualifying or Discounting the Positive Emotional Reasoning Labeling Magnification/Minimization Mental Filter Mind Reading Overgeneralization Personalization Should or Must statements Tunnel Vision

6 Slide 61 Cognitive Distortions Activity Go back through your notes of AT s Find any that fit into the categories of Basic Cognitive Distortions Do you have a favorite category Slide 62 Reviewing Therapy: Summarizing After an examination of an AT ask: How would you summarize what we just went through? What might be the most important thing for you to remember about this discussion during the next week? If the situation comes up again, what could you tell yourself instead? **Encourage clients to keep a therapy journal with these insights Slide 63 Identifying and Modifying Intermediate Beliefs Intermediate Beliefs: Rules, attitudes, assumptions Core Beliefs: Rigid, global, about self/others/world AT s are easiest to modify, then Intermediate Beliefs, then Core Beliefs In therapy, first you work with AT s but begin working on conceptualization which helps you figure out intermediate and core beliefs.

7 Slide 64 After 1 st session Therapist tool 3-4 sessions Pattern emerges Share verbally Hypothesis test Begin at bottom Cognitive Conceptualization Slide 65 Cognitive Conceptualization, Cont. When filling out, begin at the bottom Use a few typical situations with strong emotion Fill in Key automatic thought, emotion, behavior The meaning of the AT will be logically connected to Core Belief Slide 66 Cognitive Conceptualization: Core Belief Origination How did the core belief originate and become maintained? (Top box) What potentially childhood events were experienced that may have contributed to the origination and maintenance of the core belief? Some evidence may be more subtle such as childhood perceptions of the meaning of others behaviors like being different, not measuring up, etc.

8 Slide 67 Cognitive Conceptualization: Intermediate Beliefs To determine the Intermediate beliefs ask yourself: How did the patient cope with the belief? What assumptions did they make sense about life? What rules did they make in order to cope? What attitudes did they acquire to cope? Slide 68 Cognitive Conceptualization: Coping Strategies What behavior did the patient adopt in order to cope with the core belief? If I [engage in the coping strategy], then [my core belief might not come true so I will be okay]. But, if I [don t do the coping strategy], then [my core belief will probably come true]. Most coping strategies are normal in that many people engage in them the problem develops with OVERUSE of a strategy Slide 69 Cognitive Conceptualization: Activity Use a blank Cognitive Conceptualization sheet Individually look at your own list of AT s you have looked at with your colleague. Start at the bottom and fill out the sheet as far as you can

9 Slide 70 Identifying Intermediate Beliefs At times may be expressed as an AT Provide first part of an assumption statement Ask the patient about rules/attitudes Use downward arrow technique Find patterns/themes in AT s can ask Use a questionnaire Slide 71 Downward Arrow Technique Identify key AT Ask for meaning of the AT Continue to ask about the meanings of the generated list until the beliefs are discovered Questions about what a thought means will usually garner the intermediate belief Questions about what the thought means about the patient will usually glean the core belief. If they answer with feelings, ask: What is the worst part of that? Or, If that s true, what s bad about it? What does that mean about you? Slide 72 Downward Arrow Technique: Activity Pair up with a colleague Pick an AT Conduct the downward Arrow Technique starting with their chosen AT

10 Slide 73 Deciding whether or not to Modify a Belief Work on the ones that patients believe at higher rates ask for percentages Need to know: What the belief is How strongly the patient believes in it How broadly and strongly the belief impacts the patients life If now is the right time or if the patient lacks the level of objectivity to evaluate it and if there is enough time in a session. Slide 74 Educating Patients about Beliefs Use a specific example of one belief Let them know people all adopt beliefs which can be different even for similar stimuli Beliefs are learned, not innate Beliefs can be revised/rewritten Easier to change intermediate beliefs that are assumptions use the downward arrow technique to get to the meaning of rules and attitudes Slide 75 Formulating New Beliefs Useful to examine advantages and disadvantages of continuing to follow current belief Ask: What belief would be more functional? Collaborate with patient to come up with ideas that are more functional, less rigid, more realistic, more adaptive Want the Old Belief are endorsed at less than 30% intellectually and emotionally Track the changing beliefs with the Old Belief listed and under the New Belief with percentages for both

11 Slide 76 Modifying Beliefs: Techniques Socratic Questioning Behavioral Experiments Cognitive Continuum** Intellectual and Emotional Role Plays Reference Point Others Acting as if Self-disclosure Slide 77 Identifying and Modifying Core Beliefs Most central ideas of who we are Sometimes referred to as Schemas Most are positive Beck believed negative Core Beliefs fall into general categories: Helplessness Unlovability Worthlessness Developed early in life Slide 78 Difficulties with Core Belief Modification If core beliefs are rigid and overgeneralized Cannot differentiated between ideas and truth Experience severe emotion dysregulation in discussing core beliefs Have poor therapeutic alliance

12 Slide 79 Core Belief Work: Therapist Goals Hypothesize about the category from which AT s come from Specify core beliefs via techniques used to identify intermediate beliefs Present hypothesis for agreement or disagreement refine from input Educate about core beliefs Help patients develops and strengthen new, adaptive core beliefs Evaluate and modify the maintenance strategies of the negative core Belief Slide 80 Core Belief Worksheet Two columns: Evidence Supporting New Core Belief Evidence Supportive Old Core Belief with Reframe Slide 81 Other CBT Techniques Problem Solving and Skills Training Making Decisions Refocusing Measuring Moods and Behaviors with Activity Chart Relaxation and Mindfulness

13 Slide 82 Other CBT Techniques; Cont. Graded Task Assignments** Exposure Role-Playing Using Pie Technique Setting goals Determining Responsibility Self-Comparisons and Credit Lists Slide 83 Important Homework with CBT Daily Thought Record Testing Your Thoughts Worksheet