Chapter 6

My Clients Have So Many Thoughts—Which Do I Focus On?

In the previous chapter we covered identifying a trigger situation and how to understand your client’s reactions using the four-factor model. Did you have a chance to try the homework? Did you try asking your client about his or her feelings, physical reactions, or behaviors? Take a moment to reflect on what you learned from completing the homework.

If you did not do the homework, can you identify the obstacles that got in the way? Before you read this chapter, take a moment to think about an upsetting experience that happened last week. Then identify your feelings, physical reactions, and behaviors.

Don’t forget about structuring your sessions. Are you setting agendas and reviewing at the end? If you have not been using a structured session, try setting an agenda with just one client this coming week.

Set the Agenda

The next two chapters focus on how to help your clients identify their thoughts. In this chapter we will cover how to decide which thoughts are worth working on. We will call these thoughts hot thoughts. In the next chapter we will cover how to identify hot thoughts.

Work the Agenda

In CBT you are going to spend a lot of time and effort helping your clients identify and examine their thoughts. You want to be sure that time is well spent. We all have a continual stream of thoughts that go through our head every day, and not every thought is worth working on. You want to target thoughts that are central to your client’s distress and which, when targeted, will lead to meaningful change.

Agenda Item #1: Identify Hot Thoughts

Thoughts that are worth working on explain the meaning of the situation and are strongly connected to intense feelings. We call these hot thoughts (Safran, Vallis, Segal, & Shaw, 1986) because they carry emotion, and when we work with them in therapy there is meaningful change.

Here is an example. Jaylen’s father lives six hours away. He calls Jaylen once a week and always starts the conversation by sighing and saying, “I never see you. When will you come visit? I miss you.” Every week his father’s phone call triggers the same negative automatic thoughts: My father has called every week for the past two years. He is always critical. He does not appreciate what I do for him. Let’s look at Jaylen’s thoughts and identify which ones are hot thoughts. The thought My father has called every week for the past two years is a fact; it does not explain what his father’s phone call means to Jaylen or the reason for Jaylen’s emotional distress. It is not a hot thought. The thoughts He is always critical and He does not appreciate what I do for him are hot thoughts because they capture what his father’s words mean to him and explain Jaylen’s emotional reaction.

When you are first learning CBT, it can be hard to know which thoughts are hot thoughts and worth focusing on. In this chapter we are going to look at three guidelines to help you identify a hot thought. Remember, a hot thought has to capture the meaning of the situation and is related to intense feelings. Below are the three guidelines.

  1. Is this thought an unrealistic evaluation of self, others, or the future?
  2. Does this thought explain your client’s feelings?
  3. Does this thought contain a cognitive distortion?

Agenda Item #2: Is This Thought an Unrealistic Evaluation of Self, Others, or the Future?

It is your client’s unrealistic thoughts about self, others, or the future that capture the meaning of a situation and help you understand her distress.

Sometimes it is easier to understand a concept if we start with an example. A client of mine, Regina, was recently fired from a job and was feeling very depressed and anxious. When I asked what she was thinking, she responded, “I can’t believe I was fired” and “I wish I hadn’t been fired.” These thoughts do not explain what being fired means to Regina, so they are not hot thoughts. I asked additional questions and we identified the following thoughts:

Evaluation of self (thoughts that are a judgment about yourself)

Try to think of a negative evaluation that you have of yourself, or that one of your clients has of herself.

Evaluation of others (thoughts that are a judgment about other people or an expectation about how other people will treat you)

Try to think of a negative evaluation that you have of other people, or that one of your clients has of others.

Evaluation of the future (thoughts that are a judgment of the future or an expectation of what the future will be like)

Try to think of a negative evaluation that you have of the future, or that one of your clients has of the future.

When you look at the thoughts that Regina identified about self, others, and the future, can you see how they explain what getting fired meant to Regina and why these thoughts would lead to her feeling depressed and anxious?

Let’s look more closely at how to identify thoughts about self, as they can sometimes be hard to identify. Some thoughts are clearly about the self, for example, I made a serious mistake, or I am disorganized. However, sometimes negative thoughts about self are hidden in thoughts about others and in particular thoughts about how others treat you. Let’s take the thought My colleague never asks my opinion. You could believe this is the case because your colleague is unpleasant and bossy (thought about others), but you believe that you have good ideas (thought about self). In this case, the negative judgment is about your colleague and there are no negative judgments about yourself. However, you could believe that your colleague never asks your opinion because she thinks you do not have good ideas, and you think this as well. In this case, you have a negative judgment about your colleague, but you also have a negative judgment about yourself.

Here are some more examples of thoughts about others where there may be hidden negative beliefs about self: None of my new colleagues would want to be my friend, No one would want to help me, and No one will ever want to stay married to me. In all these situations, your client may believe that there is something about her that causes the other person’s negative behavior. For example, a client might think, None of my new colleagues would want to be my friend because I am too shy and boring. “I am too shy and boring” is a negative thought about self. A client could also think none of her new colleagues wants to be her friend because they are all close to retirement and are not interested in making new friends at work. In this case, there is no underlying negative evaluation of self. You can check whether there is an underlying negative evaluation of self by asking your client, “Is there something about you that would cause the other person to treat you this way?”

Your Turn! Identify Suzanne’s Thoughts about Self, Others, and the Future

In their fourth session, Suzanne wanted to talk about how upset she was with her husband. She describes a recent fight. A few nights ago her husband was watching TV when she asked him if he had bathed Andrew, their four-year-old son. He responded by saying, “I’m exhausted, can you do it?” Suzanne blew up at him, yelled that he had promised to give their son a bath and that he was selfish, and then stomped out of the room. She is feeling depressed and hopeless. Her therapist wants to understand the thoughts that caused her to become so upset. Another way of thinking about it is, what did it mean to Suzanne that her husband did not give Andrew a bath and said, “Can you do it?”

Look over the dialogue and list Suzanne’s thoughts. Then decide if the thought is a fact or an evaluation of self, others, or the future. You can find my answers in the appendix.

  • Therapist: What were you thinking when you realized your husband did not give Andrew his bath and said, “I’m exhausted, can you do it?”
  • Suzanne: I just keep thinking that he didn’t give Andrew his bath; no matter what I do, it won’t make a difference.
  • Therapist: Any other thoughts?
  • Suzanne: He doesn’t care about the kids or me. Besides, you can’t count on men.
  • Therapist: Can you tell me more about those thoughts?
  • Suzanne: I keep thinking that I’m a completely inadequate mother; I keep asking myself, Why do I have to do everything in the house?
  • Therapist: A lot of thoughts, any others?
  • Suzanne: No, that’s probably all; it’s enough!

Agenda Item #3: Does This Thought Explain Your Client’s Feelings?

The second guideline for evaluating whether your client has identified her hot thoughts is examining whether her thoughts explain her feelings, and in particular her strong negative feelings. What do I mean by this? Given your client’s thoughts, the feelings have to make sense, and the intensity of the feeling has to make sense. Let’s look at an example.

A client of mine, Angela, was concerned about her new babysitting arrangements. When her therapist asks about the situation, Angela explains that when she left her daughter with the new babysitter, her daughter cried and begged Angela not to leave. This is unusual behavior for her daughter, who loved her previous sitter and usually played happily when Angela left her with the sitter in the morning. Angela is feeling very guilty (8) and anxious (8–9). When asked about her thoughts, Angela responded, “My daughter is probably upset because it is a new sitter. She will just have to get used to her. It will take time.”

These are very good coping thoughts; however, they don’t help us understand Angela’s feelings. If she really believed these thoughts, and she had no others, would she feel guilty at 8 and anxious at 8 to 9? Probably not. Given the strength of her anxiety and guilt, there are probably some other thoughts that Angela is not aware of. Had Angela’s feelings been “slightly sad,” these thoughts would have made sense.

When your client’s thoughts don’t match her feelings, this is a sign that you need to keep exploring to identify the underlying thoughts. We will get to how you can help your clients identify their underlying thoughts in the next chapter.

Different feelings have different types of accompanying thoughts. In CBT we call this content specificity (Beck et al., 1979). Let’s look at the kind of thoughts that go with anxiety, depression, anger, guilt, and shame. Take a moment and think of the last time that you were anxious, and then focus on the feeling. What thoughts accompany this feeling of anxiety? Jot down your thoughts. Now do the same for depression, anger, guilt, and shame. See whether your own thoughts fit with the descriptions below.

How to Understand Anxiety

Thoughts that accompany anxiety are about a future threat that you think will have awful consequences, is likely to occur, and you don’t think you can handle. Figure 6.1 shows how you can think of anxiety as an equation.

Figure 6.1. Understand anxiety.

If you think you can handle the threat, it becomes a challenge. Kendall et al. (2002), in their treatment program for anxious adolescents, describe anxiety as “expecting bad things to happen.” I find this a very helpful way to think about anxiety. If your client is feeling anxious, nervous, or worried, make sure you understand what “bad thing” your client is expecting to happen. For example, in the case of Angela leaving her child with the sitter, you could say, “I hear even though you are worried, you tell yourself it will be all right, but I wonder, what are you worried will happen?”

How to Understand Depression

Depression is about loss and hopelessness. Usually when your clients are depressed, they have negative thoughts about themselves, others, and the future. Below are the kinds of thoughts you would expect someone who is depressed to have.

Thoughts about Self

  • I am inadequate.
  • I am ugly.
  • I am a bad friend.
  • I am a bad parent.
  • I am bad at sports (or work or school).
  • Nothing I do is any good.

Thoughts about Others

  • No one likes me.
  • My kids don’t care about me.
  • My colleagues think my work is no good.
  • My partner thinks I am a burden.

Thoughts about the Future

  • Nothing will ever change.
  • I will never have any friends.
  • I will never get another job.

Often depression is precipitated by a loss. It could be the loss of a relationship, the loss of health, the loss of a job, or another loss. Clients who are depressed believe that the future without what they have lost is bleak and hopeless.

How to Understand Anger

Thoughts that accompany anger usually have to do with the belief that the client or someone he cares about has been treated unfairly. Angry thoughts are usually directed at other people. Generally, the person who is angry feels disempowered, disrespected, or put down and reacts with anger. Thoughts that include “should statements” are very common. With anger there is a belief that the rules of how the world should be have been broken to the client’s disadvantage.

Anger is a complex feeling. Sometimes people have only angry feelings, especially if they believe that they have been unjustly wronged. However, anger is closely related to depression and hopelessness. If you believe you have been unjustly wronged and you believe that there is nothing you can do, you can easily become depressed. Some clients label all feelings as anger, and it can be very useful to help them recognize their other feelings.

How to Understand Guilt and Shame

Guilt and shame often go together. When we feel guilty, we believe that we have done something wrong and broken an important moral rule. Guilt is often related to believing that we have hurt someone. When we feel guilty, we feel responsible, and we tell ourselves that we should have behaved differently. Shame is closely related, as it is also connected to believing that we have broken an important rule, but we believe that because we have broken that rule, we are somehow flawed or awful. When we are ashamed, we often hide what we are ashamed about and believe we would be rejected if people knew the “real me.”

It is helpful to ask your client to specify what he did that is so terrible that he feels guilty or ashamed. Often, this is the first time that a client has articulated what it is he did. Once you have a clear idea what your client did, you can start to examine how terrible it really was.

How Intense Is the Feeling?

We have talked about the types of thoughts that you would expect to accompany specific feelings. We also expect thoughts to match the intensity of the feeling. For example, a client rates her anger at a 2 out of 10, and her thought was, I can’t stand my boss; he humiliates me every chance he gets. Given her thoughts, would you expect her anger to be stronger than a 2? I would. What if a client rates her disappointment at an 8 and her thought is, I wish I had not sprained my ankle, but even if I can’t play I can still enjoy watching the basketball game. Do you think the thought and rating go together? I don’t. Either the rating is too strong, or the client has additional thoughts that you need to identify.

Your Turn! What Thoughts Go with These Feelings?

Below are three situations. For each situation there are three possible thoughts the client might have. Choose the thought that is most likely to go with the feeling. You can find my answers in the appendix.

  1. Cameron’s college hockey team was in the state semi-final. The score was tied. Cameron had the puck and was sure he would score, when another player knocked him over. Cameron is feeling furious. What might he be thinking?
    • • Our team will never have another chance to play in the semi-finals.
    • • That guy is an animal; he should be punished; it’s unfair.
    • • If we lose, it is all my fault.
  2. Annette just heard that she was the second-choice candidate for a job she had applied for. Annette is feeling disappointed. What might she be thinking?
    • • I will never get a decent job; my life is over.
    • • They should have hired me; what idiots!
    • • I had hoped to get the job, but at least I was second choice.
  3. Orly did not visit his best friend, Roy, when Roy was in the hospital for two weeks. Orly is feeling guilty. What might he be thinking?
    • • I am a bad friend; I should have gone; I bet I hurt Roy’s feelings.
    • • My friend is probably furious at me.
    • • I bet Roy will not want to be my friend anymore.

Agenda Item #4: Does This Thought Contain a Cognitive Distortion?

The term cognitive distortion is commonly used in the CBT literature and is familiar to many therapists. However, I don’t really like it. I think the term distorted suggests that the therapist is negatively judging the client’s thoughts. McKay, Davis, and Fanning (2011) have used the term patterns of limited thinking, which I prefer. In my own clinical practice, I often use the term thinking traps because there is an inherent assumption that you can avoid a trap. I also like the term thinking style. However, for the purpose of this discussion, I’ll stick to the common term cognitive distortions.

Cognitive distortions are how your clients typically respond to situations that trigger them. You can think of cognitive distortions as a label for your clients’ negative thinking patterns. Initially, psychologists identified only a few specific distortions. Over time, the list of cognitive distortions has expanded to the point that many therapists and clients find them confusing and hard to use. It is important not to get lost in a long list. The purpose of identifying a client’s cognitive distortions is to have a label that a client feels captures his experience. Labeling a negative thinking pattern is another way of hitting the pause button on automatic negative reactions. When a client labels a thought as a cognitive distortion, he is also questioning the accuracy of his thoughts.

Below is a list of the most common cognitive distortions. I also have included in italics a number of shorthand ways of describing the cognitive distortions, which were inspired by Kendall and his colleagues (2002) and Stallard (2005). For each cognitive distortion, I have included an example from one of my clients. (Full disclosure—I snuck in one or two examples from my own life!) A Thinking Traps handout can be downloaded at http://www.newharbinger.com/38501.

Thinking Traps
Filtering: Focusing on the negative details of the situation while other positive aspects are ignored.
Overgeneralizing: You make a broad generalization, which is based on only one piece of usually negative evidence.
All-or-Nothing Thinking or Black-and-White Thinking: You or others are either right or wrong, good or bad, perfect or a failure. There is no room for grays or middle ground in evaluating yourself or others.
Mind Reading/Making Assumptions: You assume that you know what people are feeling and thinking and why they are acting that way.
Personalizing: You assume that what people are saying or doing is about you, even though there is no indication of that. Another aspect is that you often compare yourself to others, trying to determine how you measure up in a variety of attributes, such as intelligence, competence, or appearance.
Catastrophizing: You assume disaster will occur. Sometimes it is related to an initial difficulty. Catastrophic thoughts often start with “what if.” For example, your child borrowed the car to go to a party and comes home fifteen minutes late. You think, What if he had an accident? What if the car broke down?
Predicting the Future: In many ways, predicting the future is similar to catastrophizing, if the prediction is negative. However, individuals who engage in dysfunctional behavior, or who avoid completing necessary responsibilities, often falsely predict a positive or benign future.
Magnifying and Minimizing: The degree or intensity of the problem is exaggerated so that anything difficult is deemed overwhelming, and anything positive is ignored or minimized.
Shoulds: Individuals have a list of rules about how they and other people are expected to act, and they experience it as terrible if these rules are broken. They feel angry if other people break the rules, and guilty if they themselves break the rules.

If a thought contains words that indicate extremes, such as “always,” “never,” “everyone,” or “no one,” it is most likely a cognitive distortion, as the real world is not so absolute. When people use these terms, they are usually focusing only on the negative aspects of a situation and ignoring other information. This is especially true if the thought is accompanied by a strong emotional reaction. Let’s look at some examples:

In the coming week, see if you can listen to your clients’ thoughts and identify when they use terms such as “always,” “never,” “everyone,” or “no one.”

Your Turn! Identify the Cognitive Distortion

Below is a list of thoughts. See if you can identify the cognitive distortions. You will find my answers in the appendix.

  1. If I don’t get this job, my life will be over.

    Cognitive distortion:

  2. To be a good therapist, you have to give it your all and be there for your clients 100 percent of the time.

    Cognitive distortion:

  3. I’m sure that no one will ever want to hire me after this last fiasco of a job interview.

    Cognitive distortion:

  4. If I don’t help all of my clients, I am an inadequate therapist.

    Cognitive distortion:

  5. I know that my last client canceled because she thinks I’m a bad therapist.

    Cognitive distortion:

  6. A colleague told me he wondered if the group check-in should be a bit shorter next time. That was a terrible mistake I made in the first group.

    Cognitive distortion:

Help Your Clients Identify Their Cognitive Distortions

After your client has identified her thoughts, it is helpful to explain cognitive distortions. I sometimes give my client the Thinking Traps handout with the definitions of the cognitive distortions. I explain that these are common thinking styles that get people into trouble. I then ask my client to indicate whether she thinks any apply to her, and if so, to give me some examples from her own life. I make sure to tell her that identifying her cognitive distortions is an important first step.

If my client is able to identify a cognitive distortion that she commonly uses, and if the exercise seems helpful to her, I then incorporate noticing cognitive distortions into her homework. I usually ask my clients to record three situations where they caught themselves in a cognitive distortion and to record their response on the What Are My Thinking Traps? worksheet that follows, which you can download at http://www.newharbinger.com/38501.

What Are My Thinking Traps?
Situation Thoughts Thinking Trap (filtering; overgeneralizing; all-or-nothing thinking; mind reading; personalizing; catastrophizing; predicting the future; magnifying and minimizing; shoulds)

Identify Your Clients’ Cognitive Distortions Before, During, and After a Dysfunctional Behavior

I often examine my client’s cognitive distortions before, during, and after a dysfunctional behavior in order to understand what is maintaining the behavior. For example, Shula is diabetic. Despite having difficulty controlling her blood sugar levels, she frequently eats sugary desserts. She tells her therapist, “I don’t know what is wrong with me; I have no willpower. I just end up having dessert.” Let’s see what we discover when we examine her thoughts before, during, and after eating a dessert.

Shula Eats Dessert
Before/During/After Shula’s Thoughts Cognitive Distortion
Before Shula Eats Dessert

I will just have one small bite.

I had a hard day; I deserve it.

If I say no I will insult my host, who made the dessert.

Minimizing and predicting the future

Magnifying

Mind reading and catastrophizing
While Shula Eats Dessert

As long as I have eaten a little sugar, I might as well have the whole dessert.

It is too hard to keep to my eating plan.

It doesn’t matter if I eat some dessert.

All-or-nothing thinking

Magnifying

Minimizing
After Shula Eats Dessert

I am a loser.

I will never get my diabetes under control.

Black-and-white thinking

Predicting the future

Once we examined Shula’s thoughts before, during, and after she ate dessert, it made sense that she was having so much trouble keeping to a healthy eating plan. Shula had been aware of her self-critical thoughts after she ate the dessert, but she had not been aware of her thoughts before and during, and the role they played in maintaining her dessert eating.

I have had clients who tell me they “end up” drinking until they black out, having unprotected sex, or not studying for exams. The reality is people don’t “end up” doing these things. Even if it is fleeting, there is almost always a thought before the behavior that enables or justifies the dysfunctional behavior. Helping your client identify her cognitive distortions before, during, and after dysfunctional behavior is an important step in helping her feel more in control and starting a change process.

Homework: Practice CBT

Before continuing with the next chapter, take some time to try the homework.

Apply What You Learned to a Clinical Example

Complete the following exercises.

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  • Exercise 6.1: (a) Jim Forgets His Wallet, and (b) Richard’s Boyfriend Wants to End the Relationship
  • Exercise 6.2: Julie Has a Terrible Week
  • Exercise 6.3: Raymond Drinks Too Much

Apply What You Learned to Your Own Life

Look over the Thinking Traps handout for this homework assignment.

Homework Assignment #1 Identify Your Own Cognitive Distortions

Choose one or two thinking traps that resonate with you and think of a recent example from your own life for each one. This coming week, see whether you can catch any thinking traps you are currently doing and try to complete the What Are My Thinking Traps? worksheet.

What Are My Thinking Traps?
Situation Thoughts Thinking Trap (filtering; overgeneralizing; all-or-nothing thinking; mind reading; personalizing; catastrophizing; predicting the future; magnifying and minimizing; shoulds)

Homework Assignment #2 Identify Your Own Cognitive Distortions Before You Either Avoid or Act Impulsively

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The guided audio file available for this exercise also gives an example from my own life of my forever failing attempts to drink less coffee.

Think of a situation where you would like to change your behavior and where you are either avoiding or acting impulsively. For example, most of us would like to exercise more, eat less junk food, or be more organized. Choose one of these issues or a similar one. Next, think of a specific situation where you had planned to exercise but didn’t, or you ate the whole pack of potato chips when you had decided no more junk food, or instead of neatly filing your bills or reports you just left them in a pile on your desk. Once you have chosen a specific situation, think back and try to identify what your thoughts were that enabled you to not exercise, to eat the junk food, or to stick the paper onto the already messy pile of papers. Once you have identified your thought, try to identify the cognitive distortion.

Apply What You Learned to Your Therapy Practice

Now that you’ve had a chance to practice with your own thoughts, let’s turn to your clients’ thoughts.

Homework Assignment #3 Try Identifying Your Client’s Thoughts about Self, Others, or the Future

During your next few therapy sessions, when a client spontaneously mentions a thought, ask yourself if the thought is about self, others, or the future. Try to complete the worksheet below for three thoughts that a client spontaneously mentions.

Are My Client’s Thoughts about Self, Others, or the Future?
Client Thought Self, Others, or Future?

Homework Assignment #4 Help Your Clients Identify Their Thinking Traps

Choose a client who often discloses his or her thoughts and who you think would find the idea of thinking traps helpful. Give him or her the Thinking Traps handout, which is available at http://www.newharbinger.com/38501, and ask if any of the thinking traps apply. If this part of the exercise goes well, ask your client to identify and write down three thoughts that are thinking traps this coming week. You can use the What Are My Thinking Traps? worksheet.

Let’s Review

Answer the questions under the agenda items.

Agenda Item #1: Identify hot thoughts.
Agenda Item #2: Is this thought an unrealistic evaluation of self, others, or the future?
Agenda Item #3: Does this thought explain your client’s feelings?
Agenda Item #4: Does this thought contain a cognitive distortion?