The cognitive therapy intake is different from traditional intake interviews. The therapist is not only interested in the patient's symptoms and life history but also in his interpretation of events. For example, the patient may report that he felt depressed and hopeless after the breakup of a relationship and that these feelings precipitated the current major depressive episode. The therapist will inquire as to the meaning of the breakup. Therapist: You said you felt depressed and hopeless after you and Susan broke up. I am going to give you some sentences and I want you to finish them with the first thoughts that come to mind. "I felt depressed when we broke up because I thought .
Patient: I'll never be able to be with her again.
Therapist: And if I can never be with her again I feel depressed because I
think . . .
Patient: I can never be happy with anyone else.
The cognitive assessment attempts to elicit the patient's idiosyncratic interpretations of events. Unfortunately many clinicians believe they know what the event meant to the patient, but they may be completely wrong. For example, different patients might become depressed because the breakup signifies that they are unlovable, that they will not be able to care of themselves, or that they cannot trust their judgment. The patient's interpretation is key, for it will become one of the initial targets for therapy.
The cognitive therapist will try to elicit automatic thoughts, which are thoughts that come spontaneously, seem plausible to the patient, and are associated with negative affect. Typical automatic thoughts are "I'll never be happy" or "I'll lose control" or "I'm a failure." More general, pervasive thoughts are called underlying assumptions: these refer to "should statements" (e.g., "I should get the approval of everyone") and "if-then statements" (e.g., "If I don't get approval, then I'm a failure").
Many patients (especially anxious patients) report having visual images when they are anxious. These are not hallucinations, but rather images that entail the belief that something dangerous will happen. For example, a panic disorder patient had the image that she would be driving across a bridge, lose control, and see herself plummeting to her death. Positive images are often instructive because they indicate the patient's belief about how problems might be satisfactorily resolved. When the therapist asked a 45-year-old single woman what positive visual image she could produce, she began to describe herself in a bedroom holding a man she loved. This then elicited crying because she believed this would never happen. A 62-year-old married woman, reporting almost forty years of marital discord and dysthymia, had the "positive" image of her husband and herself driving on the highway, getting into an accident where she is thrown free, while he is killed. This dramatic image was positive for her: "At last I would be free of him . . . and I would not have to make any decisions." Interestingly, her image allowed her to "kill" her husband without taking responsibility for her own hostility.
Although some may believe that cognitive therapy involves the power of positive thinking, this is an incorrect evaluation. Many automatic thoughts may be true (for example, the individual may predict that he will be rejected or fail the exam) and he may be right. The question to be addressed is, "If you are rejected at the party, what would that mean to you?" The patient might respond that the future will be filled with other rejections.
Testing Automatic Thoughts
Automatic thoughts occur spontaneously, seem plausible to the patient, and are associated with negative affect. We can say that automatic thoughts are assessments or interpretations of events. They are stipulations or propositions: "I'll never be happy again," "I am a failure," or "It's all my fault." They may be either true or false. Automatic thoughts are distinguished from feelings or emotions such as sadness, anxiety, fear, or hopelessness. Feelings or emotions have the same status as sensations; they are indisputable. For example, it would make little sense to say, "Even though you feel anxious, you are not anxious." The therapist does not test or challenge whether the patient has these feelings; rather, she examines the thoughts that give rise to the feelings. For example, "I feel sad because I think I'll never succeed at anything." The therapist assists the patient in examining the proposition, "I'll never succeed at anything." Consider the following: you are walking along a dark alley in the city and you hear the footsteps of two large men coming from behind. How do you feel? Your feeling anxiety, indifference, or even elation will depend on your interpretation of the meaning of these footsteps. You might have the thought, "I'm going to be mugged!" which will lead to the feeling of fear and the behavior of escape. Or you could think, "It's just two businessmen leaving a restaurant," in which case you will have a feeling of indifference and your behavior will remain the same. You will continue your walk. Or you could have the interpretation that these are friends of yours from the psychology convention, in which case your feeling will be pleasure, and your behavior might be to turn around and try to join them. The point is that the same situation may give rise to any number of thoughts and feelings. The question is, "Which thought is valid?"
To determine which thought is valid requires examining the evidence and your reasoning. For example, you could examine the evidence by turning around and seeing who is behind you. Cognitive therapy largely consists in the elicitation and examination of the automatic thoughts and assumptions that people display when they are feeling anxious, depressed, or angry. The negative thoughts of the patient may be categorized into the following distortions:
- Mind reading: You assume you know what people think without having sufficient evidence of their thoughts. "He thinks I'm a loser."
- Fortune telling: You predict the future; things will get worse or there is danger ahead. "I'll fail that exam" and "I won't get the job."
- Catastrophizing: You believe that what has happened or will happen is so awful and unbearable that you won't be able to stand it. "It would be terrible if I failed."
- Labeling: You assign global negative traits to yourself and others. "I'm undesirable" or "He's a rotten person."
- Discounting positives: You claim that the positives you or others attain are trivial: "That's what wives are supposed to do, so it doesn't count when she's nice to me." "Those successes were easy, so they don't matter."
- Negative filter: You focus almost exclusively on the negatives and seldom notice the positives. "Look at all the people who don't like me."
- Over generalizing: You perceive a global pattern of negatives on the basis of a single incident. "This generally happens to me. I seem to fail at a lot of things."
- Dichotomous thinking: You view events or people in all-or-nothing terms. "I get rejected by everyone" or "It was a waste of time."
- Shoulds: You interpret events in terms of how things should be rather than simply focusing on what is. "I should do well. If I don't, then I'm a failure."
- Personalizing: You assign a disproportionate amount of blame to yourself for negative happenings and fail to see that certain events are also caused by others. "The marriage ended because I failed."
- Blaming: You focus on the other person as the source of your negative feelings, and you refuse to take responsibility for changing yourself. "She's to blame for the way I feel now" or "My parents caused all my problems."
- Unfair comparisons: You interpret events in terms of standards that are un-realistic; for example, you focus primarily on others who do better than you and find yourself inferior by comparison. "She's more successful than I am" or "Others did better than I on the test."
- Regret orientation: You focus on the idea that you could have done better in the past, rather than on what you can do better now. "I could have had a better job if I had tried" or "I shouldn't have said that."
- What if?: You keep asking a series of questions about "what if" something happens, and fail to be satisfied with any of the answers. "Yeah, but what if I get anxious? Or what if I can't catch my breath?"
- Emotional reasoning: You let your feelings guide your interpretation of reality; "I feel depressed, therefore my marriage is not working out."
- Inability to disconfirm: You reject any evidence or arguments that might contradict your negative thoughts. When you think, "I'm unlovable," you reject as irrelevant any evidence that people like you. Consequently, your thought cannot be refuted: "That's not the real issue. There are deeper problems. There are other factors."
- Judgment focus: You view yourself, others, and events in terms of evaluations of goodbad or superiorinferior, rather than simply describing, accepting, or understanding. You are continually measuring yourself and others according to arbitrary standards, finding that you and others fall short. You are focused on the judgments of others as well as your own judgments of yourself. "I didn't perform well in college" or "If I take up tennis, I won't do well" or "Look how successful she is. I'm not successful."
Testing and Challenging Automatic Thoughts
In evaluating and testing automatic thoughts and maladaptive assumptions or rules, the therapist may be guided by a set of questions he can pose to the patient. What if the automatic thought is true? The therapist should keep in mind that some automatic thoughts may be partly or even largely true. Cognitive therapy is not the power of positive thinking or simply the refutation of every negative belief that the patient has. When automatic thoughts are true, then the therapist may determine if behavioral changes are indicated or if the patient's underlying assumptions need to be modified. For example, a woman who had been depressed for more than two years since she was fired had the automatic thought that she interviewed very poorly. The therapist and the patient collected information about her interviews and, indeed, she had been rejected at every one of them. The therapist then engaged her in a behavioral rehearsal where she practiced her interview with the therapist during the session. It was immediately apparent that she was correct, she appeared defensive, self-absorbed, and too eager to make an impression. Therapist: It appears that your automatic thought is valid. You do come across poorly in the interview. Patient: See, it's just as I expected. I'll never get a job. Therapist: No, actually this was a great discovery. We now know exactly what you have to change in order to get a job. We now have to design good interviewing skills.
The therapist and the patient developed behavioral targets for interviewing, a list of do's and don'ts that she practiced at home using a tape recorder and rehearsed in session with the therapist. On her next two interviews she was offered jobs and now, ten years later, she has been continuously employed in a highly competitive job. The therapist should not rely on one or two challenges to a thought, since the automatic thought may have been practiced for decades. We recommend focusing on just a few central automatic thoughts per session, utilizing a variety of techniques on each thought. The following are commonly effective challenges to automatic thoughts:
Twelve Questions to Ask About an Automatic Thought
- Which cognitive distortion are you using? Are you engaging in labeling, all-or-nothing thinking, catastrophizing?
- How much do you believe in this thought?
- What are the advantages and disadvantages of this thought?
- What is the evidence for and against this thought?
- What is the quality of the evidence you are using? Could you convince a jury that your negative interpretation is the best or only valid one?
- What if the thought is true? Why would that bother you?
- Even if the thought is true, could you think of other positive behaviors that you might engage in despite this?
- If someone else had this problem, what advice would you give him?
- If someone else had this problem, would you judge him as negatively as you judge yourself? Why or why not?
- How many times in the past have you had this kind of thought? Have you ever been wrong?
- Is there something you could do to determine if this thought is true?
- If the thought is true, are there some things you can do to improve the situation?