Managing Negative Thoughts, Part 1

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Managing Negative Thoughts, Part 1: Cognitive Restructuring and Behavioral Experiments


Sarah Clark, Gemma Bowers, and Shirley Reynolds


Introduction


Negative thoughts are characteristic features of depression and anxiety and within the CBT model are seen to play a role in maintaining these conditions. This means that they are a key target for change. This chapter outlines ways of working with children and adolescents that help them manage and reduce their negative thoughts. The use of thought diaries, thought challenging, and behavioral experiments is described in relation to working with both children and teenagers across the anxiety disorders and depression.


Key Features of Competencies


Cognitive restructuring


The core principle of cognitive behavioral therapy (CBT) is that one’s emotions and behaviors are influenced by cognitions or the meaning that we attach to certain events. Helping individuals find alternative meanings or ways of thinking about events is central to changing the associated emotions and behaviors (see Chapter 8 for more detail on the theory behind CBT). However, young people often come to therapy expressing a desire to change how they feel rather than to change what they are thinking. The idea of changing their thoughts is usually not at all familiar. Therefore it is important to spend time explaining the basic CBT model and rationale. Time spent on this and on helping to develop, together with the young person, a basic formulation of his/her problems is vital and must occur before any work to challenge cognitions can begin. A description of the steps required for cognitive restructuring will be given below.


Identifying cognitions


Children and adolescents, like adults, can benefit from having some help with identifying their thoughts and finding a way to talk about them.


Talking about a recent situation in which the child or young person experienced a distressing emotion or an unwanted behavioral reaction can be a very helpful way of identifying his/her negative automatic thoughts. It can also help to socialize him/her to the CBT model and make him/her start to develop a basic formulation of the maintenance cycle (see below). In many instances, especially with younger children, including parents in this process can also be valuable, as parents may be able to offer suggestions as to what the young person was reporting at the time, while developing their own understanding of how thoughts, feelings, and behaviors are linked and how their own behaviors may be acting to maintain the young person’s difficulties.


Case example


Emily, a 14-year-old girl with social anxiety, attended weekly CBT appointments with her mother. She described feeling very uncomfortable at school, particularly in group activities or in lessons with people she described as acquaintances (rather than close friends or strangers). In order to develop a basic understanding of Emily’s experiences at school and to socialize her to the CBT model, a basic maintenance cycle was collaboratively constructed with her (see Figure 12.1). Emily’s mother also contributed to the development of the maintenance cycle by reminding her of things that she had told her about the situation being discussed.

c12-fig-0001

Figure 12.1 Emily’s maintenance cycle.

Linking thoughts and feelings

As illustrated above, Emily, like many young people, identified a range of thoughts and feelings that she experienced. One of the challenges for us, as clinicians, is to identify which thoughts match with which emotions, and consequently with which behavioral responses. For example, if the young person is reporting feelings of anxiety, we would expect the associated cognitions to have themes of anticipation of harm, whereas feelings of sadness are more likely to be accompanied by thoughts of loss (actual or impending) or self-criticism. Trying to challenge a cognition that is not linked with the target emotion is likely to have little if any effect on reducing that emotion. Although Emily reported experiencing both worry and upset in the situation described in Figure 12.1, the content of her thoughts might best be categorized as related to potential social harm coming to her; her thoughts are therefore likely to be more strongly associated with anxiety than with sadness or feeling upset.

Learning to use emotion words

Young people often have their own words for certain emotions, and it is important not to assume that their interpretation of emotional words is the same as our own. Spending time talking through a list of common emotions can be very helpful, particularly when working with younger children. Asking where they feel certain emotions in their body, or asking them to draw on a picture of the human body and coloring in where they feel certain emotions can help the therapist and the child identify together the different emotions that the child is experiencing – quite apart from the fact that it offers a fun and engaging task early in therapy. Asking young people to rate the intensity of their different emotions can also be helpful: it may contribute to identifying the most salient emotion. Then the therapist may consider which thoughts link with this particular emotion. Images such as a feelings’ “thermometer” or building blocks that show higher and lower levels of emotion, can help children and young people understand that feelings and emotions can vary in intensity (hot versus cool, high versus low) and are useful ways of helping the young person start focusing on his/her own emotions and start monitoring how (s)he changes in different situations, with different people, and in the course of a day.

Identifying images

It is also important to remember that many young people will find it easier to describe images than to describe thoughts. Asking questions such as “What was going through your mind?” or “What did you see in your mind’s eye?” encourages young people to report images as well as verbally based thoughts. More specific questions, such as “Did you notice any pictures in your mind?” or “Can you draw what was going through your mind?” can be valuable. When Emily was asked if she had any images in her mind during the situation she described above, she evoked an image of everyone at school standing in a group, looking down on her. In her image, everyone else was much bigger than her, and they were all laughing at her. When she described this image, she became visibly upset, in a way that she had not when describing her thoughts. This image, therefore, seemed important to add to the maintenance cycle formulation.

Thought diaries

Sometimes, even when therapists are creative and draw on many different methods to elicit thoughts from their clients, children and teenagers – and adults, too – struggle to identify what was going through their mind during a given situation. Here it is often helpful to encourage them to keep a record of their experiences outside of therapy sessions. This is because it is generally easier to access thoughts and images when you are as close to the situation as possible. In CBT, diaries and worksheets are often used between sessions, to record thoughts and images. These help the young person keep track of what was happening at the time – that is, of what the situation was – and of how they felt, how strong that feeling was, and what they noticed was going through their mind. There are numerous thought diaries designed for use with young people (see, e.g., Stallard 2002). However, particularly when working with adolescents, it is important to discuss with them how they would like to record their thoughts. For many, recording their thoughts on a mobile phone or on a dictaphone may be preferable to completing a paper version of a thought diary and may feel less like a school homework task. An example of a thought diary completed by Emily is shown in Table 12.1.


Table 12.1 Emily’s thought diary: Part 1.
















Situation Feelings Intensity of feeling Thoughts Distress caused by thought
Sitting in a French lesson

Worried


Upset


90%


80%


People are looking at me


They are talking about me


They will tell everybody else what they are saying about me


Nobody will like me


I won’t have any friends


75%


80%


80%


85%


90%


Apart from what goes on outside of therapy sessions, there are also important emotional shifts that occur during therapy. These give much more immediate access to the child’s ongoing thoughts and images, and therefore it is very important for therapists to be aware of changes of emotion and to be prepared to explore what the young person notices is going through his/her mind at such times. If the therapist is helping young people link thoughts and feelings within sessions, any thought-recording homework task is likely to be much more successful.

Working with negative thoughts

When the thoughts and images that are associated with the target emotion have been identified, it is important to spend time with the child or young person to acknowledge and recognize the emotional impact of these negative cognitions. This helps to validate the young person’s experience and makes him/her feel understood and “heard.” Moving on to challenging thoughts too quickly can feel dismissive to young people and may imply – or be understood as – a form of indirect criticism. Time should be given to discussing the thoughts they are experiencing in the context of their experiences and to accepting that, given their specific experiences, it is understandable that they might think the way they do.


For Emily, it was important to consider the events that precipitated the onset of these worried thoughts and feelings. She described finding the move up to high school difficult because she was separated from her close friends and remembered experiencing high levels of anxiety. At about the same time, Emily’s older brother, with whom she had previously had a close relationship, started going out more with his peers and spending less time with Emily. He also started teasing Emily about her taste in clothes and music and regularly referred to her as “weird.” Within the therapy session where this was discussed, the clinician and Emily spent time exploring how difficult this had been for Emily and how natural it was that she should tend to believe her older brother’s opinion of her. The clinician and Emily also acknowledged that, if Emily believed what her brother was saying about her, then it was understandable that she might think others were thinking similar things about her. This was even more understandable in the specific context, which was that she has started a new school and did not have the support of close friends.


Following this process of acceptance and validation, the next stage is to consider which one of the thoughts identified would be appropriate and effective to work on. A common mistake in CBT is for therapists to try to challenge thoughts that, for some reason, are difficult to shift. For example, it is not possible to challenge facts (e.g., “My mum is dead”) or questions (e.g., “Why me?”). However, questions can be turned into statements that may be challengeable; this can be done by asking questions such as: “What does it mean that this has happened to you?” Similarly, with careful questioning about the impact of events (such as a parent dying, or being bullied at school) and the meaning these events have for the young person, thoughts that are challengeable can be identified (e.g., unrealistic thoughts that have developed as a result of the event). It is also difficult to challenge central beliefs, such as “I am worthless,” early on in therapy, as these beliefs tend to be more global and rigid. Working on such beliefs too early in therapy can be overwhelming for the young person, and any shift is likely to be very small – if it occurs at all. Therefore selecting a thought that can be more easily challenged is likely to be helpful in the first instance and will instill a sense of hope in the young person that CBT might be a useful process for him/her.

Challenging thoughts

While it is important to understand and validate the reasons why a young person might be experiencing certain thoughts, it is also important to help that person develop a sense of distance from these thoughts and an understanding that thoughts are transient and fluid rather than being facts. This process was referred to by Beck, Rush, Shaw and Emery (1979) as “decentering.” A useful technique here can be asking the young person if there was ever a time when (s)he didn’t experience these thoughts in similar situations. Or “Before you felt anxious, what would have gone through your mind in this situation?” “What would your best friend/your brother/your mum think in this situation?”


Through a process of decentering, it is likely that the young person’s belief in his/her thoughts will be diminished or shaken and his/her thinking about the target situations will become more flexible. Being able to stand back from negative automatic thoughts can be very powerful. Once a sense of distance from the thought has been created and the young person has developed an understanding that thoughts are just thoughts rather than being facts, that person is much more likely to engage with the process of thought challenging and with the development of alternative thoughts and perspectives. Given that thoughts have been previously considered to be powerful and to represent reality and “truth,” the ability simply to accept that thoughts are not reality is an important shift.


Young people usually find it relatively easy to identify the evidence that supports their thoughts and to draw upon it. This process sometimes leads to their feeling even more anxious or depressed, since they focus on the evidence for the thoughts that are related to the target emotions. It is therefore important to provide young people (and their parents) with psycho-education about the fact that this is a common reaction prior to commencing this task. As a therapist, it is essential to offer a great deal of empathy during this process and to build a sense of validation – a sense that, given these experiences and this evidence, it is understandable that the young person developed such thoughts.


Finding evidence against the disturbing thought can be much more challenging. Often young people cannot think of any evidence that goes against a thought or idea they have believed in so strongly. Elaborating on, and developing, the questions that were used at the decentering stage can be useful at this point: it may help the young person gain a wider perspective.

Jan 18, 2017 | Posted by in PSYCHOLOGY | Comments Off on Managing Negative Thoughts, Part 1

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