5 The previous Chapter 4 explained Aaron Beck’s model of depression and its use in the psychoeducational and behavioral part of CBGT for depression. This chapter continues Beck’s contribution to a better understanding of the role of thinking (cognitions) in depression. The various forms of cognitive interventions all focus on increasing our clients’ awareness of the content and quality of their thinking. This chapter will concentrate on how to work with Thought Records in a group but will also review other cognitive strategies. The chapter concludes with a discussion of relapse prevention describing both CBT strategies and the Mindfulness-Based Cognitive Therapy (MBCT) approach. I feel compelled to extend the introduction to this chapter by describing Beck’s original contribution to CBT, which has greatly influenced my own commitment to CBT. Beck had extensive psychodynamic training prior to transforming himself into a cognitive therapist. As a psychodynamic clinician, he understood the importance of paying close attention to all materials produced by a patient, whether emotional or verbal. He became fascinated by what happened immediately prior to a patient expressing strong negative emotions and challenged his patients to notice what image or thought, however fleeting, they may have had. Not surprisingly, many patients were unable to name any such cognitive phenomena given that they hover on the border between subconscious and conscious awareness. Since Beck’s clinical perceptions, scores of research studies have corroborated the strong influence of preceding thoughts on emotions (see Padesky, 2004, for a detailed review). Supporting depressed clients in developing cognitive restructuring skills is a key task for CBT therapists. The restructuring of a client’s thoughts follows a number of steps. First, therapists support their clients in identifying thoughts or images that are associated with strong negative emotions. This is followed by questioning the thought, a process that encourages the client not to take the thought at face value just because it came from one’s mind, but rather to test it in order to determine its accuracy. In the previous Chapter 4, we saw how a strong negative mood can lead to thinking that is not the most accurate reflection of reality. Lastly, the examined thought may lead to the development of an alternative, or more balanced, thought that after some reflection is deemed to be a more realistic appraisal of what “things are really like.” This cycle of catch–evaluate–replace characterizes all cognitive work in CBT. Therapists who engage their clients in cognitive restructuring use synonymous terms such as dysfunctional versus functional or irrational versus rational or realistic versus unrealistic. It is up to the individual therapist to decide on the vocabulary with which they feel comfortable, and some prefer to minimize jargon when doing therapy. Substitute terms that resonate with clients include maladaptive versus adaptive or unhelpful versus helpful thinking. Many CBT therapists object to the use of the term “positive thinking.” And clients often say they have heard CBT is about having happy thoughts. Therapists will be guided by their own personal preferences, and depending on what the term happy means to them, they may or may not be comfortable using it in their therapy with depressed people. I usually refute the notion of CBT being a “power-of-positive-thinking therapy” and explain that I prefer to think of it as “reality therapy.” Part of engaging clients with CBT is to challenge them to access additional information they are unable to access when they are in the grips of a strong negative mood. Strong moods seem to tighten the cognitive restriction of our thinking, as we saw in the example of Lisa in Chapter 4, who, when upset about the cancelled lunch, locked in to a conviction that her friend secretly did not like her. I might say something like: “Your emotions are real and must be validated by you and others, but they are not always the best indicator of what is really going on for you and around you. When we are depressed or anxious, our emotional brain tends to override our intellectual one. CBT will help you reconnect with your more rational reasoning abilities. Just because you are feeling depressed or anxious, does not mean you have lost your intelligence or critical reasoning ability.” Clients appreciate the idea of using their critical thinking skills, their sound intellect. Tools called Thought Records are available to help therapists and clients replace unrealistic thinking with more realistic one. Thought Records vary from two to seven columns. The simpler ones—which are often used with children or with adults whose struggles are overwhelming—consist of just two columns contrasting the unhelpful, untrue thought, for example, “I can’t do anything right”, with a helpful, more true new thought, for example, “I do many things well and am always interested in learning”. The full 7-column Thought Record, developed by Padesky in the 1980s, is frequently used in face-to-face individual and group CBT. It is published in Mind over Mood, a self-help manual that teaches all the skills necessary to complete a 7-column Thought Record (Greenberger & Padesky, 1995). This manual is accompanied by a therapist guide, Clinician’s Guide to Mind over Mood (Padesky & Greenberger, 1995). The 7-column Thought Record is different from other kinds of Thought Records in that it evaluates a negative automatic thought or the hot thought (e.g., “my friend cancelled lunch because I bore everybody”) by examining evidence that may support the hot thought that one is boring (e.g., “It’s true that I have stopped going to choir practice and yoga class”) and evidence that does not support (e.g., “I know a lot about gardening, especially Japanese designs”). Taking both the pro and the con evidence into account, clients are assisted in developing an alternative and more balanced thought to counter the original hot thought (e.g., “While it is true that I have withdrawn from some things because of my depression, I know I have much to contribute when I hang out with people who share my interests”). With the exception of Padesky and Greenberger’s section on CBGT in their Clinician Guide (1995) and a CD course on Group Cognitive Therapy: A Balancing Act (Padesky, 2001), it is not easy to find clinical illustrations on how to work with Thought Records in a group. The main difference between using Thought Records in individual and group CBT is that the latter presents an opportunity for the therapists to use other group members to help an individual identify evidence against their hot thought. The individual person’s thinking is in a sense pitted against the reality check of several real people who offer their questions and perspectives. Also, learning about someone else’s hot thoughts, and offering them evidence against it, helps everyone to self-reflect on how easy it is to distort one’s own thinking without really being aware of this. Therapists thus tap into this collective pool of collaborative empiricism as group members help one another become curious and more objective as they “check the facts” upon which they base their thinking. The saying about there being strength in numbers rings especially true for this exercise. The following vignette shows how and, I hope, provides therapists with support and inspiration to work with individual Thought Records while engaging the entire group. Therapist: Juanita: Cotherapist: Juanita: Cotherapist: Cotherapist: Juanita: Cotherapist: Juanita: Cotherapist: Juanita: Susan: At this juncture, there is potential for the entire exercise to derail and fall apart. This can happen in a number of ways. When people share similar automatic thoughts, the desire to offer mutual support is strong, and the group easily becomes more of a process group. In order to demonstrate the value of working with Thought Records, it is important that at least one individual example gets completed during a group session. The onus is upon the therapists to keep track of time and gently return the attention of the group to the individual example, in this case, Juanita’s. However, therapists also take the opportunity to comment on how any individual Thought Record example often has relevance for many people. All group members are encouraged to write down Juanita’s example on their own sheets. Another example of derailing is when a therapist accepts a negative automatic thought that is about another person without inquiring further. In Juanita’s example, it would be to put the following thought “my mother is selfish” in column 3. Occasionally, a therapist may mistakenly accept a negative automatic thought about another person and write it down in column 3. This is where cofacilitation is helpful. If one therapist begins to become a bit stuck, the cotherapist can jump in and ensure the Thought Record exercise is brought back on track. This involves a literal return to the drawing board. It is imperative that we do not accept negative automatic thoughts when they are statements about other people. Doing that gets us into trouble as it is impossible to evaluate whether someone else in a client’s life is, for instance, “a jerk.” They may or may not be. The point is that the negative thought must always be about the person in question. The therapist deals with this by asking what it may mean to the group member to believe that “your brother is a jerk?” The member may say: “That I’m weak and cannot stand up to him.” This is an appropriate automatic thought for which evidence for and against can be examined. In the same way, in the case of Juanita, it would not be helpful to engage in a discussion of what her mother is like, but rather to stay with how Juanita’s experience of her mother as judgemental and selfish gives rise to a number of self-critical thoughts. Therapist: Juanita: Raymond: Cotherapist: Juanita: Cotherapist: Brendan: Therapist: Brendan: Juanita: Cotherapist: Juanita: Therapist: Juanita: Cotherapist: Devin: Brendan: Juanita: Ivana: Juanita: Ivana: Ricardo: Juanita: Therapist: Juanita: Cotherapist: Juanita: Cotherapist:
CBGT for Depression: Cognitive Interventions and Relapse Prevention
The Thought Record in a Group
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CBGT for Depression
We’re now going to work through another Thought Record example. Is there somebody who had a challenging situation last week where they felt a strong mood?
Yes, I did and I’m still upset and scared because it involved my mother and I’m going to see her on the weekend, but have decided I just will not go to this family dinner [starts crying].
It seems very timely, Juanita, and maybe we can review what happened and be able to support you. Can you tell us what the situation was? [Cotherapist goes to the board and sketches the seven columns: 1. Situation, 2. Moods, 3. Automatic Thoughts (images), 4. Evidence That Supports the Hot Thought, 5. Evidence That Does Not Support the Hot Thought, 6. Alternative Balanced Thoughts, 7. Rate Moods Now.]
On Saturday I went shopping with my mom, and she bought a bunch of makeup, and I just bought one small bottle of body lotion. She then called me Saturday evening accusing me of being irresponsible because she knows I have some debt to pay off.
Yes, you’ve talked about that problem and we can understand how the interaction with your mother was upsetting. Under “Situation,” I’ll write: at home by myself Saturday night talking to my mother on the telephone. [The therapist reminds the group that it is important that only the bare bone situation is described including who, what, when, and where]. Appendix D shows Juanita’s completed Thought Record.
What did you feel? [It makes sense to have the therapist who is starting the Thought Record and standing by the board do much of the questioning for the first three columns].
Upset, angry, scared, threatened, helpless, and depressed.
OK, what would be the most intense feelings and how would you rate their intensity?
Scared, 90%, angry, 70%, and helpless also 90%.
OK, makes sense that these feelings were pretty intense. What was going through your mind when you began to feel questioned by your mother?
That I don’t like her, and that she is a selfish person who just happens to have a lot more money than I do. What right does she have to criticize me?
That’s like my mother too, I so often feel this disapproval of how I manage my life, and especially my finances, but I don’t know how to tell her to back off.
Juanita and Susan, we understand your frustration and we will have opportunities to work more on your relationship to your mothers, but for this exercise, Juanita, what does it say about you that your mother is being critical of the way you manage your finances?
I worry that my mother is right. I wish I could stand up to her though. I don’t trust myself handling money. I’m acting like a child. Maybe I am a selfish person. I’m certainly a financial failure. What if I go broke and become homeless?
No, Juanita, all that is not true about you. From what I see in our group, you’re not selfish.
I appreciate your reaction, Raymond, and if you hang on, we’ll soon get to the part of discussing what is or is not true about Juanita. Juanita, of those thoughts and fears you named, which one seems to carry the most energy for you right now? Which one would you like us to work with?
I think the one about being a financial failure—because it comes up a lot for me these days and not just when I’m with my mother.
[Circles the “I’m a financial failure” thought]. Now, I want the group to imagine we are in a sense a judge or a jury in a courtroom and Juanita is on trial for being “a financial failure.” How would we arrive at a fair judgment?
I’m not sure, but I think it would involve looking at the evidence for and against her case.
Precisely. So based on what we know about Juanita, and what you know about yourself, Juanita, what evidence can we point to in support of this idea of a failure? What questions would we ask to get more information?
Is it true that you do have debt you want to pay off?
Yes, I have faltered on my debt payment plan for a second time.
OK, that does sound like some hard piece of evidence, so I’ll write that down in column 4. Anything else?
I’m also keeping this debt a secret from my husband, and know I’m being dishonest.
OK, although not disclosing your debt is not necessarily indicative of being a financial failure, we’ll write it down as it does provide some evidence for the way you think about yourself. Any other evidence for your being a financial failure?
No, it’s mostly about not living within my means and having failed so far to follow the plan for financial recovery as outlined by my bank advisor.
Let’s move on to column 5. What is some evidence against Juanita being a financial failure? (Further questions to help with completing column 5 are given in the Mind over Mood protocol (Greenberger & Padesky, 1995)).
Juanita is in therapy and working on her issues. That suggests strength and success to me.
Yes, and she listens and is open to advice. Remember I suggested she talk to an advisor at her bank as they are free. It sounds like you did that Juanita?
I did—and thanks for that advice, Brendan. My advisor is really helpful and optimistic. I’m certainly far from bankruptcy.
Did you say some weeks ago that your work hours have been cut back, Juanita?
Yes, my hours have been scaled back and I’ve lost about 20% of my income.
I think that’s important too. I don’t know about the rest of you, but I live from paycheck to paycheck and would be in trouble if my income declined.
I’m curious, Juanita, about whether your struggle to stay out of debt has always been a problem or is it more recent?
No I did fine when I was in college and in fact a girlfriend came to me for some advice for saving money [laughs in midst of tears]. It’s something that has slowly happened over the past four years. I guess since I began to feel more depressed.
Excellent questions, Ivana and Ricardo. Juanita, do these examples of evidence against your hot thought fit for you?
It sort of does, but still a bit hard to accept.
OK, I’ll write it all down. Juanita, is there anything else you would like to add? [The therapist may comment on how it was easy for Juanita to quickly come up with evidence in column 4 suggesting she is a “financial failure,” but much more difficult to offer counterevidence in column 5 without help from the group. This is common and, again, reminds us of how hard people with depression can be on themselves].
Not really, but it’s funny how you’ve all helped me to remember that I wasn’t always hopeless at managing my money. I know I can do it; it’s just that I’ve lost what it takes. Although I don’t want to blame circumstances, I do see that my lesser income is certainly not making it easier for me either.
Anyone else have a question for Juanita? If not, and in the interest of time, we will now as a group step back and look at the evidence in both columns 4 and 5. [The therapist reads each piece of evidence for and against the possibility that Juanita is a financial failure]. Our next challenge is to come up with a balanced statement about Juanita’s money situation, a statement that is fair and takes the evidence both for and against the possibility that she is a “financial failure” into account. How can we put the essence of both columns together into one sentence or statement? [Further questions to help with column 6 are given in the Mind over Mood protocol (Greenberger & Padesky, 1995).]
