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As he developed stronger symptoms of depression, he started avoiding additional tasks he thought he wouldn’t do well, for example, paying bills and doing yard work. He had many automatic thoughts across situations about the likelihood that he would fail. These thoughts led him to feel sad, anxious, and hopeless. He viewed his difficulties as due to an innate flaw and not as the result of encroaching depression. He developed a generalized sense of incompetence and helplessness and curtailed his activities further. His relationship with his wife became quite strained, and they started having significant conflict. He interpreted the conflict as meaning he was failing in the marriage, that he was incompetent as a husband.
Over the course of several months, Abe’s problems at work became even worse. Joseph became quite critical of Abe and downgraded him at his yearly performance review. Abe’s depression intensified significantly when his wife filed for divorce. He became preoccupied with thoughts of how he had let her and his children and his boss down. He felt like (that is, he had a belief that he was) an incompetent failure. He felt (believed he was) at the mercy of his sad and hopeless feelings (“I’m out of control”) and thought there was nothing he could do to feel better (“I’m helpless”). And then he lost his job.
Then use CBT techniques on yourself if any client comes to mind. Identify your cognitions about this client and do one or more of the following:
- Evaluate and respond to your cognitions about the client; create a coping card to read.
- Check on your expectations for your clients. Work on accepting them and their values as they are.
- Check on your expectations for yourself. Make sure they’re realistic.
- Specify your concern and conceptualize: What might the client do or say (or not do or not say) in session (or between sessions) that could be a problem? Which beliefs might underlie this behavior?
- Cultivate nondefensiveness and curiosity.
- Problem-solve by yourself or with a colleague/supervisor.
- Set appropriate limits with clients.
- Work on accepting your own emotional discomfort.
- Do good self-care throughout the day (e.g., deep breathing, taking a walk, calling a friend, doing a short mindfulness practice, eating in a healthy way).
CLIENT 2: These forms are a waste of time. Half the questions are irrelevant.
THERAPIST: What’s the worst part about filling them out?
CLIENT 2: I’m busy. I have a lot to do. If my life fills up with meaningless tasks, I’ll never get anything done.
THERAPIST: I can see you feel pretty irritated. How long does it take you to fill them out?
CLIENT 2: … I don’t know. A few minutes, I guess.
THERAPIST: I know some of the items don’t apply, but actually they save us time in our session because I don’t have to ask you lots of questions myself. Could we try to problem-solve and see where you could fit in the time to do them?
CLIENT 2: (Sighs.) I guess it’s not that big a deal. I’ll do them.
Here I avoid directly evaluating the accuracy of the client’s automatic thoughts because he is annoyed and I sense that he will perceive such questioning in a negative way. Instead, I provide a rationale and help the client realize that the task is not as time consuming as he has perceived it to be. In a third case, I judge that further persuasion to fill out forms will negatively affect our tenuous therapeutic alliance.
Abe, for example, has to stay home to fix an active leak under the sink, so he can’t attend his grandson’s soccer game. He thinks, “Ethan will be so disappointed.” His thinking then becomes more extreme: “I’m always letting him down.” He accepts these thoughts as true and feels quite sad. After learning tools of CBT, however, he’s able to use his negative emotion as a cue to identify, evaluate, and respond adaptively to his thoughts. In another situation, Abe was able to respond to a similar automatic thought in this way: “Wait a minute, her parents are going to be at there [at her dance recital]. She may be a little disappointed that I’m not. And it’s not true that I’m always letting her down. I’ve gone to lots of her performances.”
You seek to identify automatic thoughts that are dysfunctional—that is, those that
- distort reality,
- are associated with an unhelpful emotional and/or physiological reaction,
- lead to unhelpful behavior, and/or
- interfere with clients’ sense of well-being and ability to take steps to reach their goals.
Like Maria, some clients believe that negative emotions are unsafe: “If I get upset, _____,” for example, “it will get worse and worse until I can’t stand it, I’ll lose control, it will never go away, or I’ll end up in the hospital.” These kinds of beliefs can interfere with working to achieve their goals. Clients may avoid situations in which they predict they will become upset. They may avoid talking about or even thinking about distressing problems. When clients have dysfunctional cognitions about experiencing negative emotion, they may not make much progress in treatment. You can use standard cognitive restructuring techniques to help clients evaluate their beliefs. Doing a behavioral experiment using mindfulness (pp. 278–279) is especially effective. When clients successfully disengage from a thought process such as worry, you can guide them in changing their cognitions from “Worry is uncontrollable” to “I can choose to disengage in worry when I notice it has started.”
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.
this is actually great
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.