By Michael D. Anestis, M.S.
Cognitive behavioral therapy (CBT) is founded on the now well-established principle that our thoughts, emotions, and behaviors all influence one another, and that thoughts offer one of the most straightforward and effective points of intervention. In our article on behavioral activation (CBT Skills Part 1), we focused primarily on how behaviors can influence symptoms of depression. Here, we intend to shift that focus towards the manner in which thoughts can induce, increase, and prolong symptoms of depression as well. Throughout this article, I will refer to a fictional clinician named Dr. Meehl and a fictional client named Jane.
When Jane comes in for her first session of CBT for depression, one of Dr. Meehl's initial goals is to provide thorough information on the nature of depression and the theory and structure of CBT. In this initial stage, Dr. Meehl explains the concept of automatic thoughts - thoughts that occur immediately in response to stimuli (internal or external). For example, if a co-worker is slow to respond to a comment, Jane might experience an automatic thought such as "she thinks I'm stupid." This is not surprising, given that Jane is feeling depressed, but there are, in fact, many reasons that could explain the person's delayed response, most of which are not nearly so negative. Expanding upon this idea, Dr. Meehl then explains that, in depressed individuals, there is a tendency to experience dysfunctional automatic thoughts. These dysfunctional thoughts seem reasonable to Jane, but they actually do not reflect reality. What is particularly problematic about such thoughts is that they have a direct impact on the Jane's emotions, causing the her to experience unnecessary states of negative affect. At this point, Dr. Meehl provides the client with a list of common types of dysfunctional automatic thoughts, including:
- Dichotomous Thinking -- Viewing the world in entirely black and white terms. (e.g., Jane indicates she is not making any progress in therapy because she is not entirely healed rather than noting the graded improvements she has made since her initial session).
- Fortune Telling -- Jane indicates that she knows the outcome of an event that has not yet occurred, even though such knowledge is impossible. (e.g., Jane says that there is no way another individual would want to go on a date with her even though she has never asked)
- Discounting Positives -- Jane explains away any positive outcome or accomplishment as meaningless (e.g., "I did well on that exam because it was easier than the other ones, but I fail when there is a real challenge").
- Mind Reading -- Jane indicates that she knows what other individuals think (e.g., "That person hates me") regardless of the level of evidence in support of or against her conclusion.
After explaining the various types of common dysfunctional automatic thoughts, the priority of Dr. Meehl then becomes to train Jane to identify and label such thoughts. This accomplishes two main goals. First, Jane begins to see her thoughts as just thoughts rather than facts and thereby takes a step back and considers the situation objectively rather than relying purely upon gut impulses. Second, it provides both Dr. Meehl and Jane with a clear list of common thoughts Jane has been experiencing and thus clarifies high priority targets for cognitive restructuring.
There are numerous cognitive restructuring techniques, including cost-benefit analyses (e.g., "what are the costs and benefits of this belief?"), semantic techniques (e.g., defining vague words such as "good" or "bad" in concrete terms with clear methods of evaluation rather than making broad unfalsifiable negative statements), and double-standard techniques (e.g., "would you view a friend the same way you view yourself if your friend committed this same supposed offense?"). Here, we will focus on one such technique - examining the evidence for and against the particular thought.
Quite simply, this technique asks Jane to treat each thought as a hypothesis and to act like a scientist by testing thoughts, examining the evidence for and against their veracity. At first, Jane may resist this approach for a variety of reasons. She may claim not to have thoughts before her emotions or indicate that she can not possibly remember to challenge them in the moment. Dr. Meehl must encourage Jane to practice repeatedly between sessions and to resist judging herself for difficulties she experiences, comparing this technique to any other difficult skill acquired over time. Jane might also mistakenly believe that Dr. Meehl wants her to replace distorted negative thoughts with equally distorted positive ones. This is an important point to clarify. Cognitive restructuring in general and examining the evidence for and against thoughts in particular will not ask Jane, the client who believes "nobody likes me," to think "everybody loves me." Instead, these techniques ask Jane to ask "what evidence do I have that nobody likes me?" "what evidence do I have that some people do like me?" and "what specific things can I do to make clearly identifiable gains in this area?" In other words, this technique asks Jane to be fair, recognize the evidence, and revise her thoughts to better reflect reality. If something is going poorly, the evidence will reflect that. Depressed individuals, however, tend to overstate the frequency and severity of negative outcomes and so, by examining the evidence for and against her beliefs, Jane can decrease the amount of time spent believing that things are going poorly (or at least as poorly as she believes them to be).
What Jane will quickly realize is that, even when a highly negative automatic thought is revised to simply be slightly less negative, the result is less negative emotion. What is most interesting about this is that the revised thought, since it is based on examining actual evidence, is actually a more accurate reflection of reality. In other words, at least a portion of the sadness, frustration, anger, or other negative emotion Jane was feeling was a direct result of misinterpreting or inaccurately viewing the world around her. Thinking in more objective terms will enable Jane to feel better immediately. Building off the example above, if Jane believes that "nobody likes me," Dr. Meehl might ask her to explain how she knows that others do not like her. Jane will likely indicate that others ignore her or do not call her often. Dr. Meehl then might ask Jane if she dislikes all people she fails to interact with regularly. Additionally, Dr. Meehl will ask Jane to list all positive interactions she has had with other individuals, what made those interactions positive, and how the other individuals behaved in those situations. The goal in this example is to bring Jane's attention to positive experiences she has been downplaying or ignoring and to make observable clear behaviors and statements be the basis of her interpretations. This technique on its own is simply one CBT skill, not intended to be used in isolation or expected to resolve all symptoms, but it is a powerful tool that can help people to alter the manner in which they react to their own thoughts.
So, if you are not a clinician, how can you incorporate cognitive restructuring into your daily life? Step one is to notice each time you're in a bad mood during the course of the coming week. When you notice your negative mood, write down the thoughts you're having in that moment. Do not worry about grammar or alter the thought to make it sound better. Simply write what you think. Try to do this as soon as you have the thought, so you can remember it accurately and challenge it while you are still feeling the emotion that was prompted by the thought. Next to the thought, write down what emotion you feel in response to the thought and how strongly you feel it (e.g., on a scale from 1-100). After this, write down all of the evidence you can think of that is supportive of that thought. Next to that, write down all of the evidence you can think of that runs counter to your thought. Be thorough in both categories so that you are completely fair and objective. After considering all of this evidence, write down a revised version of your thought that better reflects all of the evidence (e.g., I wish I had more friends, but there are several people who truly care for me."). Finally, write down what emotion you feel in response to the new thought and how strongly you feel that emotion. Chances are, the results are significantly happier than what you were experiencing when you first had the initial thought and that your revised thought offers you a suggestion for steps you can take to improve your situation.
If you think you might be experiencing symptoms of depression, however, do not simply try these skills on your own. Although this would be a good start, you are significantly more likely to benefit from treatment in a clinical setting. For more information on how to find a therapist who utilizes CBT, please consult our list of EST clinics.
For more information on cognitive restructuring in particular and CBT in general, please consult PBB contributor Robert Leahy's manual Treatment Plans and Interventions for Depression and Anxiety Disorders
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Mike Anestis is a doctoral candidate in the clinical psychology program at Florida State University.
