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You can use any set of questions to help clients evaluate their thinking, but the lists can be helpful as they guide you and the client to
• examine the validity of the automatic thought,
• explore the possibility of other interpretations or viewpoints,
• decatastrophize the problem situation,
• recognize the impact of believing the automatic thought,
• gain distance from the thought, and
• take steps to solve the problem.
All-or-nothing thinking
Also called black-and-white, polarized, or dichotomous thinking. You view a situation in only two categories instead of on a continuum.
Example: “If I’m not a total success, I’m a failure.”
Catastrophizing (fortune-telling)
Also called fortune-telling. You predict the future negatively without considering other, more likely outcomes.
Example: “I’ll be so upset, I won’t be able to function at all.”
Disqualifying or discounting the positive
You unreasonably tell yourself that positive experiences, deeds, or qualities do not count.
Example: “I did that project well, but that doesn’t mean I’m competent; I just got lucky.”
Emotional reasoning
You think something must be true because you “feel” (actually believe) it so strongly, ignoring or discounting evidence to the contrary.
Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.”
Labeling
You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less extreme conclusion.
Examples: “I’m a loser”; “He’s no good.”
Magnification/minimization
When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive.
Example: “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.”
Mental filter
Also called selective abstraction. You pay undue attention to one negative detail instead of seeing the whole picture.
Example: “Because I got one low rating on my evaluation [which also contained several high ratings], it means I’m doing a lousy job.”
Mind reading
You believe you know what others are thinking, failing to consider other, more likely possibilities.
Example: “He’s thinking that I don’t know the first thing about this project.”
Overgeneralization
You make a sweeping negative conclusion that goes far beyond the current situation.
Example: “Because I felt uncomfortable at the meeting, I don’t have what it takes to make friends.”
Personalization
You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior.
Example: “The repairman was curt to me because I did something wrong.”
“Should” and “must” statements
Also called imperatives. You have a precise, fixed idea of how you or others should behave, and you overestimate how bad it is that these expectations are not met.
Example: “It’s terrible that I made a mistake. I should always do my best.”
Tunnel vision
You only see the negative aspects of a situation.
Example: “My son’s teacher can’t do anything right. He’s critical and insensitive and lousy at teaching.”
What is the situation? You might be having thoughts about something that just happened in the environment or something that happened inside of you (an intense emotion, a painful sensation, an image, a daydream, a flashback, or a stream of thoughts—e.g., thinking about my future). I got a parking ticket.
• What am I thinking or imagining? I’m so stupid.
• What is the cognitive distortion? (optional) Labeling, overgeneralizing
• What makes me think the thought is true? I shouldn’t have lost track of time.
• What makes me think the thought is not true or not completely true? Other people get parking tickets. It doesn’t necessarily mean they’re stupid.
• What’s another way to look at this? I just made a mistake.
• If the worst happens, what could I do then? Just keep paying parking tickets, but it would be better to set an alarm on my phone so it doesn’t happen again.
• What’s the best that could happen? I’ll never get a parking ticket again.
• What will probably happen? I could get another ticket, but I’ll probably remember what happened this time and make sure I don’t.
• What will happen if I keep telling myself the same thought? I’ll keep being upset with myself.
• What could happen if I changed my thinking? I’d feel better.
• What would I tell my friend or family member [think of a specific person] Gabe if this happened to him or her? It’s not that big a deal. So you forgot and made a mistake. You know how to avoid doing this in the future.
• What would be good to do now? Get my mind off of this. Go for a walk.
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Beck (1999) theorized that negative core beliefs about the self fall into two broad categories: those associated with helplessness and those associated with unlovability. A third category, associated with worthlessness (Figure 3.2), has also been described (J. S. Beck, 2005). When clients are depressed, their negative core beliefs may primarily fall into one of these categories, or they may have core beliefs in two or all three categories. Some have just one belief within a category; others have multiple beliefs within one category.
Sometimes it’s clear in which category a given negative core belief belongs, especially when clients actually use words such as “I am helpless” or “I am unlovable.” At other times, it’s not as clear. For example, depressed clients may say, “I’m not good enough.” You need to find out the meaning of cognitions like these to determine whether clients believe they are not good enough because they haven’t achieved enough (helpless category), or if they believe they’re not good enough for others to love them (unlovable category). Likewise, when clients say, “I’m worthless,” they may mean that they don’t achieve highly enough (helpless category) or that they won’t be able to gain or maintain love and intimacy with others because of something within themselves (unlovable category). The cognition “I’m worthless” falls in the worthlessness category when clients are concerned with their immorality or toxicity, not their effectiveness or lovability.
The goal of CBT is not to eliminate negative emotion. All emotions are important. Negative emotions frequently point to a problem that needs to be solved (which may or may not include changing one’s thinking)—or, if it can’t be solved, accepted. The goal of CBT is to reduce the degree and duration of negative emotion that doesn’t seem to be proportionate to the situation (given the client’s culture and circumstances), usually related to distorted or unhelpful perceptions. Acceptance of negative emotion (instead of avoidance) is key for some clients (Linehan, 2015; Segal et al., 2018). Acceptance and commitment therapy (Hayes et al., 1999) describes useful metaphors for accepting negative emotion and turning one’s attention to valued action.
It is rare that personality problems are the chief complaint of a patient presenting for treatment. Instead, difficulties with depression, anxiety, or external situations compel the patient into treatment. Personalitydisordered patients will often see the difficulties they encounter in dealing with other people as generally independent of their own behavior or input. They will frequently describe being victimized by others or, more globally, by “the system.” Such patients are apt to have little idea about how they got to be the way they are, how they contribute to their own problems, or how to change. Other patients are very much aware of the self-defeating elements of their problems (e.g., overdependence, inhibition, and excessive avoidance) but remain unaware of the personality aspects or the role of personal volition in change.
The typical dysfunctional beliefs and maladaptive strategies expressed in personality disorders make individuals susceptible to life experiences that impinge upon their cognitive vulnerability. Thus, the dependent personality disorder is characterized by a sensitivity to loss of love and help; the narcissistic by trauma to self-esteem; the histrionic by failure to manipulate others to provide attention and support. The cognitive vulnerability is based on beliefs that are extreme, rigid, and imperative. We speculate that these dysfunctional beliefs have originated as the result of the interaction between the individual’s genetic predisposition and exposure to undesirable influences from other people and specific traumatic events.
Among the basic components of the personality organization are sequences of different kinds of schemas that operate analogously to an assembly line. For purposes of simplification, these structures may be viewed as operating in a logical linear progression. For example, exposure to a dangerous stimulus activates the relevant “danger schema,” which begins to process the information. In sequence, then, the affective, motivational, action, and control schemas are activated. The person interprets the situation as dangerous (cognitive schema), feels anxiety (affective schema), wants to get away (motivational schema), and becomes mobilized to run away (action or instrumental schema). If the person judges that running away is counterproductive, he or she may inhibit this impulse (control schema).
In Axis I disorders, a specific mode becomes hypervalent and leads, for example, to preoccupation with loss, danger, or combat. In the case of depression, a chain reaction is set up: cognitive → affective → motivational → motor. In personally meaningful situations, the interpretation and the affect feed into the “effector loop” or action system. For instance, after her interpreting a rejection, a sad expression would sweep across Sue’s face. This process, which occurred automatically, might have served phylogenetically as a form of communication—as a distress signal, for example. Concomitantly, “action schemas” were triggered: Her own particular strategy for dealing with rejection was activated, and she experienced an impulse to go into the next room and ask Tom to reassure her. She was mobilized to act according to her stereotyped strategy. At this point, she might or might not yield to her impulse to run to Tom.
Self-appraisals and self-evaluations are important methods by which people can determine whether they are “on course.” Whereas selfappraisal may simply represent observations of the self, self-evaluation implies making value judgments about the self: good–bad, worthwhile– worthless, lovable–unlovable. Negative self-evaluations are found overtly in depression but may operate in a more subtle fashion in most of the personality disorders.
In normal functioning, this system of self-evaluations and self-directions operates more or less automatically. People may not be aware of these self-signals unless they specifically focus their attention on them. These cognitions may then be represented in a particular form labeled “automatic thoughts” (Beck, 1967). As noted earlier, these automatic thoughts become hypervalent in depression, and they are expressed in notions such as “I am worthless” or “I am undesirable.”
The self-evaluations and self-instructions appear to be derived from deeper structures: namely, the self-concepts or self-schemas. In fact, exaggerated negative (or positive) self-concepts may be the factors that move a person from being a “personality type” into having a “personality disorder.” For example, the development of a rigid view of the self as helpless may move a person from experiencing normal dependency wishes in childhood to “pathological” dependency in adulthood. Similarly, an emphasis on systems, control, and order may predispose a per- son to a personality disorder in which the systems become the master instead of the tool—namely, obsessive–compulsive personality disorder.
Even though this disorder is not included in DSM-IV-TR, we have found that a significant number of patients have behaviors and beliefs indicative of this disorder. Individuals with passive–aggressive personality disorder have an oppositional style, which belies the fact that they do want to get recognition and support from authority figures. The chief problem is a conflict between their desire to get the benefits conferred by authorities on the one hand and their desire to maintain their autonomy on the other. Consequently, they try to maintain the relationship by being passive and submissive, but, as they sense a loss of autonomy, they are inclined to resist or even to subvert the authorities.
Self-view: They may perceive themselves as self-sufficient but vulnerable to encroachment by others. (They are, however, drawn to strong figures and organizations because they crave social approval and sup-port. Hence, they are frequently in a conflict between their desire for attachment and their fear of encroachment.)
View of others: They see others—specifically, the authority figures— as intrusive, demanding, interfering, controlling, and dominating, but at the same time capable of being approving, accepting, and caring.
Beliefs: Their core beliefs have to do with notions such as “Being controlled by others is intolerable,” “I have to do things my own way,” or “I deserve approval because of all I have done.”
Their conflicts are expressed in beliefs such as “I need authority to nurture and support me” versus “I need to protect my identity.” (The same kind of conflicts are often expressed by borderline patients.) The conditional belief is expressed in terms such as “If I follow the rules, I lose my freedom of action.” Their instrumental beliefs revolve around postponing action that is expected by an authority, or complying superficially but not substantively.
Threat: The main threat or fears revolve around loss of approval and abridgement of autonomy.
Strategy: Their main strategy is to fortify their autonomy through devious opposition to the authority figures while ostensibly courting the favor of the authorities. They try to evade or circumvent the rules in a spirit of covert defiance. They are often subversive in the sense of not getting work done on time, not attending classes, and so on—ultimately self-defeating behavior. Yet, on the surface, because of their need for approval, they may seem to be compliant and cultivate the goodwill of the authorities. They often have a strong passive streak. They tend to follow the line of least resistance; they often avoid competitive situations and are interested more in solitary pursuits.
Affect: Their main affect is unexpressed anger, which is associated with rebellion against an authority’s rules. This affect, which is conscious, alternates with anxiety when they anticipate reprisals and are threatened with cutting off of “supplies.”
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