The middle phase working with negative automatic thoughts

Once behavioural methods have been mastered, patients learn to identify and question negative automatic thoughts, so as to reduce distress and find constructive solutions to their problems. The main tool here is the Dysfunctional Thoughts Record, illustrated in Fig 3, which summarizes a lengthy discussion that took place when the patient experienced a serious setback midway through treatment.

Fig. 3 Dysfunctional Thoughts Record.

Identifying negative automatic thoughts

Patients learn to record upsetting incidents as soon as possible after they occur. This is because delay makes it difficult to recall thoughts and feelings accurately. Patients are taught the following.

1. To identify unpleasant emotions (e.g. despair, anger, guilt). Changes in emotional state are cues that negative thinking is present. Each emotion is rated on a 0 to 100 scale, where 100 means that the emotion is as strong as it could possibly be, 50 that it is moderately strong, and so on. These ratings (though the patient may initially find them difficult) help to make small changes in emotional state obvious when the patient begins the search for alternatives to negative thoughts. This is important, since change is rarely all-or-nothing and small improvements may otherwise be missed.

2. To identify the problem situation. What was the patient doing or thinking about at the time the painful emotion occurred (e.g. "waiting at the supermarket checkout", 'worrying about my husband being late home')?

3. To identify negative automatic thoughts associated with the change in emotional state. Sessions are geared towards the point where the therapist can ask the patient: 'And what went through your mind at that moment?' Patients become aware of the thoughts, images, or implicit meanings that are present when emotional shifts occur, and record them word-for-word. Belief in each thought is also rated on a 0 to 100 per cent scale (100 per cent represents complete belief, 50 per cent a moderate degree of belief, and so on). Again, this is to make small changes in conviction evident at the next stage.

The skill of identifying painful emotions and associated thoughts is best learned if therapist and patient work through examples on the sheet before the patient self-monitors independently. The therapist can be sure that the patient understands what is required, and is prepared for possible difficulties. For example, patients sometimes avoid recording thoughts because to do so is upsetting. The therapist can reassure them that this phase will pass as they learn to answer their thoughts, and suggest that they follow recording by engaging in an absorbing and pleasurable activity. Sometimes thoughts recorded do not seem to 'fit' the emotion experienced; in this case, the therapist may need to help the patient to 'unpack' the meaning of the thought (for example, 'I didn't do that too well' may on inquiry turn out to mean 'I'm a total failure'). Time taken to self-monitor accurately will vary; many patients acquire the skill within a few days, but others take much time and coaching.

Questioning negative automatic thoughts

Once patients can observe and record thoughts and feelings, they then learn to search for alternative views, recording these in the fifth column of the Dysfunctional Thoughts Record. There is no such thing as a 'right' answer to a negative thought; the 'right' answer is the one that helps the patient to feel better and handle the situation more constructively. Accordingly, the therapist's task is not to suggest alternative perspectives, but rather to elicit them through 'guided discovery', a process of sensitive questioning which allows patients to reach new interpretations independently. It is helpful for therapists to develop a personal 'library' of questions, through discussion with colleagues, observation of other therapists, attendance at workshops, and written texts. (4 5 and 51 Some productive areas of inquiry are given below.

1. What is the evidence? Processing biases in depression mean that patients give weight to information consistent with negative automatic thoughts at the expense of information which suggests that they may not be wholly true. The therapist thus needs not only to examine evidence held to support the thought, but also to seek information that might contradict it.

2. What alternative views are there? Alternative perspectives may emerge in response to questions such as the following: 'How would you have reacted to this before you became depressed?' 'What is your perspective on this when you feel relatively well?' 'What might someone whose views you trusted make of this?' 'If someone you cared about came to you with this problem, what would you say?'

3. What are the advantages and disadvantages of this way of thinking? This approach is particularly helpful with self-critical thinking. Patients often believe that self-criticism is an effective way of bringing about change; in fact, it leads only to an intensification of depression. Patients who habitually self-criticize can be helped to draw up an analysis of pros and cons. Perceived advantages (e.g. 'It keeps me on my toes') may in fact be outweighed by disadvantages (e.g. 'It paralyses me, so I can't think what to do').

4. What errors am I making in my thinking? The tendency in depression to make inferential errors such as overgeneralization and personalization has already been mentioned. Learning to recognize these can be helpful, especially when patients regularly make the same mistake.

Alternatives reached by questioning negative automatic thoughts are recorded on the Dysfunctional Thoughts Record. The patient rates them for degree of belief, to ensure that they are sufficiently convincing (they do not necessarily require belief ratings of 100 per cent). If alternatives are not at all convincing, even theoretically, they will have no impact on the strength of the original automatic thoughts or associated emotions. These are now re-rated in the final column as a check that plausible alternatives have been found.

5. What can I do now? It is important that cognitive changes brought about by questioning are consolidated through behavioural assignments. These are often designed to test out the validity of the new perspective by seeking further information or acting differently and observing the results. They may also include practical plans to solve genuine life problems and to deal with the trigger situation differently should it occur again.

As with self-monitoring, these skills are best learned by working through examples in session before the patient attempts to answer thoughts independently. Even then, patients may find that they are sometimes unable to find alternatives, especially if emotion is high. They can be reassured that this is normal, given that questioning one's thoughts is a complex skill. It may be helpful to leave searching for alternatives until the storm is past. Sometimes alternatives make no difference to the original thoughts or emotions. This may be because the patient has reservations about their validity ('Yes, but...'), which can dealt with like other negative thoughts. Alternatively, it may emerge that the resistant thought is a more or less direct statement of an underlying belief of much longer duration. Initially, this can simply be noted for future reference.

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