Demystifying CBT: Effective, easy-to-use treatment for depression and anxiety

Evaluating cognitive distortions

Thought records. Automatic thoughts are the cognitive content that runs through our minds moment to moment and that we can access by asking ourselves, “What was going through my mind when I felt (emotion)?” Automatic thoughts can exist as:

• verbal messages (“I can’t believe this!” or “I’m such a loser”)
  
• or images (“I picture my boss screaming at me”).
  

Teach patients to monitor their experiences by writing down their thoughts and feelings as well as the corresponding situations when they feel strong negative emotions. Compared with psychodynamic therapies—which emphasize retrospective reconstruction of childhood experience—self-monitoring with a “thought record” focuses on the present, is more accessible, and is less prone to recall bias.

Self-monitoring also facilitates “decentering,” or viewing one’s emotional experience from a distance, which may be crucial to therapeutic success.⁹ By using Socratic questioning (Table 3) and guided discovery, you teach patients to evaluate their automatic thoughts as hypotheses to be tested.

If patients discover that their automatic thoughts are inaccurate, you can help them construct more-balanced or alternate appraisals. Conversely, hypothesis testing may help generate new solutions if the process validates the patient’s initial interpretation of a situation.¹⁰

Table 3

Examples of Socratic and non-Socratic questioning

Socratic questioning What evidence do you have to support this idea? How strongly do you believe this now? On a scale of 0 to 100%, where does your belief fall? Where do other people’s fall? How does this thought affect how you feel and act? Can you describe experiences when this thought was not completely true? If a close friend thought this way, what would you tell him or her? If you told a close friend about this thought, what would he or she say? When you have felt differently in the past, what would you have said about this thought? Are any distortions present in the thought you identified? Non-Socratic questioning Why are you being so hard on yourself? You say you are a total loser. Would a total loser have accomplished all the things you did this week? I’m sure that others don’t see you this way.

Labels for distorted thoughts. Help patients identify and label their cognitive distortions. These distortions are systematic biases in information processing that reinforce negativistic thinking in depression or catastrophic thinking in anxiety. Examples include:

• overgeneralization (“Nothing ever works out for me”)
  
• all-or-nothing thinking (“I failed again” [after getting 95% on an exam])
  
• mind-reading (“My boss thinks I’m incompetent”)
  
• catastrophization (“My heart is racing; I think I’m having a heart attack!”).¹¹
  

Intermediate beliefs may emerge as automatic thoughts or be identified in thought records as consistent themes. These underlying beliefs represent idiosyncratic vulnerabilities that make a person susceptible to distress or decompensation in a given stressful situation. They take the form of:

• attitudes (“Weakness is contemptible”)
  
• rules (“I will not let others take advantage of me”)
  
• conditional assumptions (“If I let others take advantage of me, I’m a thoroughly weak person”).
  

A man with the above intermediate beliefs who acquiesces to a friend’s request for a loan might perceive that the friend has taken advantage of him. Emotionally, he may react with sadness, despair, or anger. You and he can evaluate these beliefs through a thought record and view them as hypotheses to be tested with behavioral experiments.

Framing the intermediate belief as a conditional assumption can help accomplish this goal. Presumably, the patient was distressed about loaning money to his friend. When pressed, he says he didn’t want to lend the money but felt he couldn’t say no. He identifies his automatic thought as “I’ve been taken advantage of.” Asked what this means if it is true, he replies, “If I get taken advantage of, it means I’m weak.”

Core beliefs are deeper cognitive structures that are not always immediately accessible, although they may occasionally emerge spontaneously as automatic thoughts. They are overgeneralized, absolute statements that fall into one of two categories:

• affiliation (“I am bad,” “I am unlovable”)
  
• competence/vulnerability (“I am weak,” “I am helpless”).
  

Core beliefs can be identified by using the downward arrow technique (Table 4). After an automatic thought is identified, repeatedly ask the patient, “If that were true, what would that say about you/others/the world?” or, “What would be the worst thing about that if it were true?”

Very often, intermediate and core beliefs must be defined in a measurable way before you can help the patient test them. For the man feeling distressed about loaning money, for example, you might ask him to define “being taken advantage of ” or define “weak” by listing all the characteristics he associates with this label.