The enclosed techniques and procedures were developed with materials from a workbook of cognitive behavior techniques titled ‘Thoughts & Feelings’ and written by Matthew McKay, Martha Davis and Patrick Fanning. The workbook was published by New Harbinger Publications, Inc. In 1997.
NOTE: This technique, combined with CBT#02 & CBT#03 provides the basic protocol for Cognitive Process Correction [See CBP#10] and combines the strategies of Beck and Ellis for identifying and changing irrational thoughts.
Clinical Prompt
The beginning of any technique starts with a trusting relationship with the child. Thus, the Mentor will need to weigh how much of the following can be used to build trust, and how much trust is necessary before proceeding further.
- engage the child in a formal dialogue about events, thoughts, feelings & behavior
- outline the process of perceiving reflex thoughts
- indicate the time for mastery
- identify negative feedback, chains or sequences
- check to be sure the child understands all language & concepts – this should be done repetitively until you are confident that the child understands
- ask the child to share the process with his/her family
- review the 10 characteristics of reflex thoughts
- ask the child to identify one of his/her own reflex thoughts
- use the recollection technique if necessary
- prod for ‘chains’ – extend as far as possible
- begin to try to ‘catch’ thoughts in situ
- start a Thought Journal
- review the Thought Journal
- begin questioning how true the thoughts are
Depending on the age or style of the child, the Mentor may want to cast this process as one of finding a powerful skill or knowledge with which the child can control his own life and experiences.
Introduction
Thoughts cause feelings. This is the essential insight of cognitive intervention. All cognitive techniques flow out of this one simple idea: that thoughts cause feelings. The many emotions people feel are preceded and caused by a thought, however abbreviated, fleeting, or unnoticed that thought may be.
Events by themselves have no emotional content. In fact, event have no meaning at all until the person give it meaning. It is the interpretation of an event that causes the emotions. The perceptions of an event are given meaning as good or bad, pleasant or unpleasant, and this disposition leads to the identification of an emotion. This is often represented as the “ABC” model of emotions:
A. Event ——————> B. Thought ——————-> C. Feeling
Because we tend to react to events that are important to us with emotions, we tend to overlook or skip the reflex thoughts which fuel the feelings. In order to get the child to understand this process, you will need to develop a formal dialogue in which you consistently ask the child to tell you what s/he is thinking at the critical moments. When a teacher chastises, or another student harasses – what is the thought that quickly goes past almost unnoticed?
It may be helpful to cite examples:
- Event: You are late to your locker and then cannot get the combination to work.
- Thought: You interpret the event by saying to yourself, “Oh no, This is awful; I’m stuck—I’ll be late.”
- Feeling: You experience an emotion appropriate to your thoughts. In this case, you may feel depressed and anxious about being late. Or perhaps you will feel anger, because you believe that someone else made you late.
Most people are able to readily identify A & C. It is B, their thoughts and beliefs which you will wish to identify and with which they will require some degree of assistance.
Once you get to know the child and his/her experiences, you should be able to use actual experiences in the examples. But examples are good – they demonstrate that other people may have some unusual thoughts as well.
Change the thought and you change the feeling. If the child who is your client had a thought, “The teacher is calling on me to make me look stupid”, s/he is likely to have felt anger. If s/he had thought, “The teacher is calling on me because she likes me”, the emotions might have indeed been different even if there was anxiety about the ability to answer the question.
As a cognitive trainer you will need to be able to help children learn to become aware of and attend to the automatic or reflex thoughts in such a way as the ones just described. These thoughts are like automatic or nonconscious behaviors such as blinking your eyes. You can control eye blinking, but this requires that you hold this control consciously. This takes a certain amount of energy. Identifying or recognizing reflexive thoughts and consciously attending to them also takes energy. Teaching a child how to do this is a basic skill you will need to master in order to use cognitive techniques to reduce painful feelings which lead to counterproductive behavior(s).
Symptom Effectiveness
By itself, uncovering reflex thoughts is not considered a full-scale technique. It is the first step in many different cognitive behavioral approaches. However, the client may feel some immediate reduction in anxiety, depression, or anger as a result of exploring how they react to upsetting situations. This is a good sign that cognitive intervention is likely to help him or her quickly.
On the other hand, it is more likely that s/he will not experience any improvement in symptoms by using only this skill. In fact, some feelings may actually intensify as a result of exploring them. If you consider that this is an early step along the way and subsequent techniques will build upon this one, there is no cause to worry.
Time for Mastery
Most people make significant progress during the first week of faithfully keeping a Thought Journal CBT#01-001. The longer they practice tuning into their automatic thoughts, the better they get at it. It’s a skill like knitting, skiing, writing, or singing on key—practice makes for improvement and continued practice for continued improvement.
Instructions
Negative Feedback Loop
The Event ————> Thought ————-> Feeling sequence is the basic building block of emotional life. But the building blocks can become very jumbled and confusing. The emotional life of real people is not always a simple series of ABC reactions, each with its discrete starting event, thought, and resultant feeling. More often a series of ABC reactions join in a feedback loop. The ending feeling from one sequence becomes the starting event for another sequence.
In the case of painful feelings, a negative feedback loop can be set up in which an uncomfortable feeling itself becomes an ‘event’, the subject of further thoughts, which produce more painful feelings, which become a larger event inspiring more negative thoughts, and so on. The loop continues until the person works him/herself into a rage, an anxiety attack, or a deep depression.
Feelings have physiological components. When the child experience emotions such as fear, anger, or joy, the heart speeds up, s/he breathes faster and less deeply, s/he sweats more, and the blood vessels contract and dilate in different parts of the body. ‘Quiet’ emotions such as depression, sadness, or grief involve a slowing down of some of the physiological systems. Both the emotion and the accompanying bodily sensations trigger an evaluation process – the person starts trying to interpret and label what they feel.
You need to help the child identify the thought(s), feeling(s) and the physiological reactions that go with the feeling(s). It is important to note that concepts and language are a major part of the training you are providing. You are not providing a service which the child cannot understand. You are explaining each detail of the process in a manner in which the child can take control. By helping the child understand the concepts, you help the child take charge. By understanding the language, you help the child make the process cognitive instead of emotional. The very ability to put a word to how you feel makes it possible to bring the feeling into conscious space and control it.
The child will need to understand and begin to search for the negative loops in his/her own thinking and how these loops affect their performance. For example, if the child did not complete his/her homework, the negative feedback loop might go like this:
- Event: I don’t have my homework.
- Thought: “Oh no, this is awful. I’ll be embarrassed by the teacher.
- Feelings: Heart beating fast, feeling hot and sweaty, irritation, anxiety
- Thought: “This is really bad!” If the teacher looks over here, I will look away! I’ll hide!
- Feelings: Stomach clenching, hard to breathe, dizzy, fear
- Thought: “I’m freaking out … I’ll lose control…. Can’t move … can’t get safe.”
- Feelings: Strong adrenalin rush, panic
- Resulting behavior
The Nature of Reflex Thoughts
You will need to help the child understand that all people are constantly describing the world to themselves, giving each event or experience some label. In addition, all people automatically make interpretations of everything they see, hear, touch, and feel. They judge events as good or bad, pleasurable or painful, safe or dangerous. This process colors all of their experiences, labeling them with private meanings. The purpose of this understanding is to 1) help the child both see themselves as like all other people and 2) to begin to think about what reflex thoughts other people may be having in relation to themselves.
These labels and judgments are fashioned from the unending dialogue that the person has with him/herself, a waterfall of thoughts cascading down the back of the mind. These thoughts are constant and rarely noticed, but they are powerful enough to create the most intense emotions. This internal dialogue is called self-talk or automatic or reflex thoughts. The person perceives these thoughts as though they are by reflex—without any prior reflection or reasoning; and they impress him as plausible and valid.” (Beck 1976)
As a review of your own training, and the training that you must give to your client, we remind you that reflex thoughts usually have the following characteristics:
- They often appear in shorthand, composed of just a few essential words phrased in telegraphic style: “lonely . . . getting sick . . . can’t stand it . . . cancer . . . no good.” One word or a short phrase functions as a label for a group of painful memories, fears, or self-reproaches.An automatic thought needn’t be expressed in words at all. It can be a brief visual image, an imagined sound or smell, or any physical sensation. A woman who was afraid of heights had a half-second image of the floor tilting and felt herself sliding down toward the window. This momentary fantasy triggered acute anxiety whenever she ascended above the third floor.Sometimes the automatic thought is a brief reconstruction of some event in the past. A depressed woman kept seeing the stairway in Macy’s where her husband had first announced his plan to leave her. The image of the stairway was enough to unleash all the feelings associated with that loss.Occasionally an automatic thought can take the form of intuitive knowledge, without words, images, or sense impressions. For example, a chef who was plagued with self-doubt “just knew” that it was useless to try to get promoted to head chef.
- Reflex thoughts are almost always believed, no matter how illogical they appear upon subsequent analysis.For example, a man who reacted with rage to the death of his best friend actually believed for a time that his friend deliberately died to punish him.Reflex thoughts have the same believable quality as direct sense impressions. You attach the same truth value to automatic thoughts as you do to sights and sounds in the real world. If you see a man getting into a Porsche and have the thought, “He’s rich; he doesn’t care for anyone but himself,” the judgment is as real to you as the color of the car.
- Reflex thoughts are experienced as spontaneous. You believe automatic thoughts because they are automatic. They seem to arise spontaneously out of ongoing events. They just pop into your mind and you hardly notice them, let alone subject them to logical analysis.
- Reflex thoughts are often couched in terms of rules: should, ought, or must. A woman whose husband had recently died thought, “You ought to go it alone. You shouldn’t burden your friends.” Each time the thought popped into her mind, she felt a wave of hopelessness. People torture themselves with “shoulds” such as “I should be happy. I should be more energetic, creative, responsible, loving, generous….” Each ironclad “should” precipitates a sense of guilt or a loss of self-esteem.”Shoulds” are hard to eradicate, since their origin and function is actually adaptive. They are simple rules to live by that have worked in the past. They are templates for survival that you can access quickly in times of stress. The problem is that they become so automatic that you don’t have time to analyze them, and so rigid that you can’t modify them to fit changing situations. Of greatest significance, however, is when these ‘rules’ lead to exaggerated negative emotions and counterproductive behavior.
- Negative automatic thoughts tend to “awfulize.” These thoughts predict catastrophe, see danger in everything, and always expect the worst. A stomachache is a symptom of cancer, the look of distraction in a lover’s face is the first sign of withdrawal. “Awfulizers” are the major source of anxiety.Awfulizers are also hard to eradicate because of their adaptive function. They help you predict the future and prepare for the worst-case scenario.
- Reflex thoughts are relatively idiosyncratic. In a crowded theater a woman suddenly stood up, slapped the face of the man next to her, and hurried up the aisle and out the exit. The witnesses to this event reacted in different ways.One woman was frightened because she thought, “She’s really going to get it when they get home.” She imagined the details of a brutal beating and recalled times when she had been physically abused. A teenager was angry because he thought, “That poor guy. He probably just wanted a kiss and she humiliated him. What a bitch.” A middle-aged man became depressed when he told himself, “Now he’s lost her and he’ll never get her back.” He could see his ex-wife’s face set in angry lines. A social worker felt a pleasurable excitement as she thought, “Serves him right. I wish some timid women I know had seen that.”Each response was based on a unique way of viewing the stimulus event and resulted in a different strong emotion.
- Automatic thoughts are persistent and self-perpetuating. They are hard to turn off or change because they are reflexive and plausible. They weave unnoticed through the fabric of your internal dialogue and seem to come and go with a will of their own. One automatic thought tends to act as a cue for another and another and another. You may have experienced this chaining effect as one depressing thought triggers a long chain of associated depressing thoughts.Such automatic thoughts are plausible because they are consonant with you beliefs about yourself and other people. If you believe that rich people don’t care about others, the sight of a person getting into a Porche might cause you to believe that s/he was rich and then automatically the next thought, s/he doesn’t care about other people follows. It seems to be triggered by the event, and in fact, is. However, the beliefs system is embedded in your own value system – making it familiar and seemingly appropriate.
- Automatic thoughts often differ from your public statements. Most people talk to others very differently from the way they talk to themselves. To others they usually describe events in their lives as logical sequences of cause and effect. But to themselves they may describe the same events with self-deprecating venom or dire predictions.
- One executive calmly explained aloud, “Since I got laid off, I’ve been a little depressed.” This matter-of-fact statement differed sharply from the actual thoughts that unemployment triggered in him: “I’m a failure . . . I’ll never work again . . . My family will starve … I can’t make it in this world.” He had an image of himself spiraling down into a bottomless black pit.
- Automatic thoughts repeat habitual themes. Chronic anger, anxiety, or depression results from a focus on one particular group of automatic thoughts to the exclusion of all contrary thoughts. The theme of anxious people is danger. They are preoccupied with the anticipation of dangerous situations, forever scanning the horizon for future pain. Depressed individuals often focus on the past and obsess about the theme of loss. They also focus on their own failings and flaws. Chronically angry people repeat automatic thoughts about the hurtful and deliberate behavior of others.Preoccupation with these habitual themes creates a kind of tunnel vision in which you think only one kind of thought and notice only one aspect of your environment. The result is one predominant and usually quite painful emotion. Beck has used the term selective abstraction to describe this tunnel vision.Selective abstraction means looking at one set of cues in your environment to the exclusion of all others.
- Reflex thoughts are learned. Since childhood people have been telling you what to think. You have been conditioned by family, friends, and the media to interpret events a certain way. Over the years you have learned and practiced habitual patterns of automatic thoughts that are difficult to detect, let alone change. That’s the bad news. The good news is that what has been learned can be unlearned and changed.
How are you going to teach these ten principles to your client? Methods will vary based upon the age and other characteristics of the child. But it is important that there be a repetitive dialogue about these factors. Do not expect to tell the child once, and have them absorb these concepts. Further, you will need to feed these principles one at a time. The concept of a formal dialogue is to ensure that you develop a script every day which reminds you to discuss concepts and language with the child. You know that these ten concepts will need to be mentioned in some form with every early contact, until you are sure that the child is able to understand and use these concepts on their own.
Further, you will want to use the Basic Thought Journal CBT#01-001 as a means of reinforcement.
Listening to Reflex Thoughts
Hearing automatic thoughts is the first step in gaining control of unpleasant emotions. Most of a person’s internal dialogue or self talk is harmless. The automatic thoughts that cause harm can be identified because they almost always precede a continuing painful feeling.
To identify the automatic thoughts that are causing a continued painful feeling, the client should be helped to try to recall the thoughts s/he had just prior to the start of the emotion and those that go along with the sustained emotion. Help them think of it as listening in on an intercom. The intercom is always on, even while they are conversing with others and going about life. They are functioning in the world and they are also talking to themselves at the same time. Tell them to ‘listen in on the intercom of your internal dialogue, and hear what you are telling yourself’. ‘Your automatic thoughts are assigning private, idiosyncratic meanings to many external events and internal sensations’. ‘They are making judgments and interpretations of your experience’.
Reflex thoughts are often lightning fast and very difficult to catch. The child needs somehow to find a way in essence to ‘catch themselves blinking”. The thoughts flash on as a brief mental image, or are telegraphed in a single word. You can provide two methods for coping with the swiftness of these thoughts:
- Have the child reconstruct a problem situation, going over it again and again in their imagination until the painful emotion begins to emerge. Ask “What are you thinking as the emotion comes up?” The child should regard these thoughts as a slow- motion film. Look at the internal dialogue, frame by frame. Notice the millisecond it takes to say, “I can’t stand it,” or the half-second image of a terrifying event. Help the child to notice how s/he is internally describing and interpreting the actions of others: “She’s bored…. He’s putting me down.”By reconstructing the problem situation, the child is able to slow down the emotional reactions and back up to the thoughts.
- Have the child stretch out the shorthand statement into the original statement from which it was extracted. “Feeling sick” is really “I’m feeling sick and I know I’m going to get worse. . . . I can’t stand it.” “Crazy” means “I feel like I’m losing control, and that must mean I’m going crazy…. My friends will reject me.”By spelling out the entire chains or sequences of thought, the child is lengthening the thoughts and the time that they are available. Hearing the shorthand isn’t enough. It is necessary to listen to the entire interior argument in order to understand the distorted logic from which many painful emotions bloom. By lengthening the thoughts and putting them into longhand, the child is keeping the thoughts in the conscious arena, where they can be analyzed and reviewed.
It is critical to recognize that these irrational or distorted thoughts generally are linked together. It will be necessary to continue coaxing the child [‘What else?”] to elicit a full range of thoughts that add up to or convey the extremely negative emotional reaction. Left to themselves, a child may only identify a small section of the ‘chain’. They will need help and practice to uncover all of the reflex thoughts in any given situation.
Recording Thoughts
To appreciate the power of these reflex thoughts and the part they play in the emotional life, the child should be encouraged to keep a Thought Journal. While the child may feel inadequate about writing out these thoughts and feelings, s/he must be helped to feel comfortable with you and your acceptance of his/her level of competence. You don’t care if s/he can spell or write in sentences, and you are certainly advised to keep from being critical. This is not what the Journal is about. Each step is oriented toward slowing down the process so that it can be captured and controlled. The child should be encouraged to write out in whatever form s/he is capable of doing. Perhaps it is helpful to think of it as a personal diary which is shared only with you as a private confidant.
As soon as possible after the child experiences an unpleasant feeling, s/he can record it in the Thought Journal.
The form is self-explanatory, except for how to rate feelings. The Thought Journal allows the child to assess the distress level with a scale running from 0 (the feeling causes no distress) to 100 (the most distressing emotion they have ever felt).
Make several copies of this journal for the child and have them carry it with them at all times. If the child is fearful that someone else may get the Journal, you may want to have them give you the page after it is completed and you will keep it private. You and they will use the material generated in the Thought Journal.
Have the child use the Basic Thought Journal CBT#01-001 for one week, making an entry only when the client feels a painful emotion. They may find that concentrating on automatic thoughts makes the feelings worse for a while. Keep them working on it – it’s normal to feel worse before they start to feel better.
The process of perceiving reflex thoughts may also make the child begin to distrust these thoughts and begin questioning and disputing them as they pop up. The techniques of changing patterns of limited thinking, give you specific tools for disputing automatic thoughts.
At this point it is important for the child to recognize that thoughts create and sustain emotions. To reduce the frequency of painful emotions, they will first need to listen to what they think, then ask how true it is. What you think will ultimately create what you feel.
Special Considerations: Thought Counting
Sometimes automatic thoughts come so quickly and in such abbreviated form that the child can’t identify them, even though s/he knows s/he just had some. In that case, you can simply have the child count the thoughts.
Each time s/he notice that s/he has had an automatic thought, s/he is to make a mark on a three by-five card that you will provide and that s/he carry with him/her. Counting automatic thoughts helps get some distance from them and a feeling of control. Rather than assuming that automatic thoughts are an accurate assessment of events, you are helping them note them and then let them go. Once the child has counted a thought, they need not dwell on it.
This process will eventually slow the thoughts and sharpen the attention so that the actual content of the thoughts starts to become clear. When that happens, the child may want to continue counting, this time categorizing the thoughts and counting how many they have of various types: catastrophic thoughts, loss thoughts, insecure thoughts, and so on.
If the child has difficulty and forgets to count the thoughts, have them set a watch alarm or a timer to go off every twenty minutes. When the alarm or timer goes off, have them stop what they are doing and look inside themselves. They should then count any negative thoughts they notice.
Sharing with the family
Children should be encouraged to share the process and the thoughts with their parents. However, many will want to keep the thoughts private, at least for a while until they get control of them. You should honor this confidence, but insist that the technique that your are working on be shared. The parents and other family members will need to ‘stand up and be counted’ as supporters of the child or not. In order to offer support, they will need to understand the process. Some parents may even find the process helpful to themselves. If the child can become the trainer of adult family members in the technique, it helps him/her own and understand the technique. If the adult is able to share thoughts with the child, it will firm up the child’s ability to share. Families are an interactive system and mutual involvement is very beneficial. You should share with the Clinical Supervisor these issues and ask that the person(s) working with the adult family members help the family address and support this process.