The enclosed technique 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#01 & CBT#02 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.
The beginning of any technique starts with a trusting relationship with the child. Since this is the third technique in the cognitive process correction protocol, the Mentor should have established a sanctioned and helping relationship. If this does not feel comfortable, talk to your Clinical Supervisor about the situation and consider what of the following actions to take.
This is an alternative technique which will require a great deal of thought and writing. The writing may be done by the Mentor.
- review special considerations
- photocopy the Thought & Evidence Journal
- select the most distressing [trigger] thought from the original thought journal
- identify evidence to support the thought
- uncover evidence against the thought
- ask the ten key questions
- record the answers
- write out alternative thoughts
- re-rate mood
- record and save alternative thoughts on three by five cards
- visualize/expose trigger and alternative thoughts
- create an action plan
- 3’ by 5’ cards
If the previous techniques worked well for the client, this technique may not be necessary. This is an alternative approach based on evidence gathering and analysis that provides a powerful weapon against automatic thoughts. When used in conjunction with, ‘Perceiving Reflex Thoughts’, it will teach the child skills to do three things: (1) identify the evidence that supports distressing (or trigger) thoughts, (2) uncover evidence that contradicts these distressing thoughts, and (3) synthesize what they have learned into a healthier, more realistic perspective.
Gathering evidence on both sides of the question is crucial to reaching a clearer, more objective understanding of the experience. Albert Ellis (Ellis and Harper 1961) was the first to develop a method (rational-emotive therapy) to evaluate evidence for and against key beliefs. But by assuming that distressing thoughts are always irrational, and focusing mostly on the evidence against them, his approach may not always feel objective. It also may alienate children who have solid evidence to support certain thoughts. Christine Padesky (Greenberger and Padesky 1995), building on Beck (1976) and Ellis’s work, developed the strategies for gathering and analyzing evidence used in this technique. Padesky did not assume that distressing thoughts are totally irrational. She focused instead on looking at all the evidence and working toward a balanced and rational position.
Thought Journals have been used effectively to treat depression, anxiety, and related problems. Numerous studies over the past twenty years demonstrate the usefulness of this technique.
Time for Mastery
Using the Thought and Evidence Journal can make significant changes in the child’s moods in as little as one week. However, it will take from two to twelve weeks to consolidate some of these changes, allowing the new, more balanced thoughts to gain strength through repetition.
Photocopy the blank Thought and Evidence Journal so you can have a supply of pages to use whenever you need one.
Step 1: Select a Distressing Thought.
Return to the Thought Journal that the child began keeping earlier to select a ‘trigger’ thought from their record of reflex thoughts. Help the child choose a thought that impacted their mood either because of its power or frequency. Have the child rate each thought on a scale (0-100) that measures how strongly it contributed to their painful feelings. Have them circle the thought with the highest score – that’s the ‘trigger’ thought you’ll work on first.
When working with children, it is sometimes helpful to place the endeavor into a context or role to which they might easily relate. Depending on the age of the child, it may be helpful to couch this process as one of an investigative reporter, a detective or a scientist. We are looking for solid, objective evidence that will support or oppose the ‘trigger’ thought.
Step 2: Identify Evidence that Supports Trigger Thought.
Now have the child write down the experiences and the facts that would appear to support their distressing thought. This is not the place to have them put their feelings, impressions, assumptions about the reactions of others, or unsupported beliefs. In the column marked ‘Evidence For’, insist that the child stay with the objective facts. Confine them to exactly what was said, what was done, how many times, and so on. While it’s important to stick with the facts, it’s also important to acknowledge all the past and present evidence that supports and verifies the trigger thought.
Don’t include conjectures, assumptions, or a ‘feeling’. Confine the child to the facts and an objective description of events.
Step 3: Uncover Evidence against Trigger Thoughts.
The child will probably find this to be the hardest part of the technique. It’s easy to think of things that support your distressing thoughts, but s/he will often draw a blank when it’s time to explore evidence against it. S/he will most likely need some help.
To assist the child in the search for evidence against trigger thought, there are ten key questions that as a good reported, scientist or detective you need to ask. Go through all ten questions for every trigger thought you are analyzing – each of them will help the child explore new ways of thinking.
Ten Key Questions
- Is there an alternative interpretation of the situation, other than your trigger thought?
- Is the trigger thought really accurate, or is it an overgeneralization? Is it true that (the situation) means (the trigger thought)?
- Are there exceptions to the generalizations made by the trigger thought?
- Are there balancing realities that might soften negative aspects of the situation?
- What are the likely consequences and outcomes of the situation? This question helps the child differentiate what they fear might happen from what they can reasonably expect will happen.
- Are there experiences from the client’s past that would lead them to a conclusion other than the trigger thought? Identify positive experiences.
- Are there objective facts that would contradict items in the ‘Evidence For’ column? Are there facts at odds with this interpretation?
- What are the real odds that what the client fears happening in the situation will actually occur? Help the child think like a bookmaker. Are the odds 1 in 2, 1 in 50, 1 in 1,000,1 in 500,000? Think of all the people right now in this same situation; how many of them end up facing the catastrophic outcome that the clients fears?
- Does the child have the social or problem-solving skills to handle the situation differently? If not, can you teach them these skills or is there a place that they can learn the skills?
- Could the child, with your help, create a plan to change the situation? Is there someone that they know who they think might deal with this differently? What would that person do?
Have the child write on a separate piece of paper the answers to all of the questions relevant to their trigger thought. Or, it that is not feasible, write the responses down as you discuss with them these questions . It may take some thinking: to find exceptions to the generalization created by the trigger thought; to think objectively about the odds of something catastrophic happening; or to recall balancing realities that give them confidence and hope in the face of problems. The Mentor should support the child in working through these problems, intervening only to be supportive. The work the child puts into this step in the evidence-gathering process will directly impact their ability to challenge trigger thoughts.
The child may find it particularly useful to look for objective facts that either counterbalanced or contradicted each item in the ‘Evidence For’ column. S/he should keep asking him/herself, “What in my experience balances out this piece of evidence?” and “What objective facts contradict this piece of evidence?”.
Step 4: Write the Alternative Thoughts.
Have the child read over both columns slowly and carefully. S/he should not try to deny or ignore evidence on either side. Now have him/her write new, balanced thoughts that incorporate what has been learned from the gathered evidence. In the balanced thoughts it’s OK for the child to acknowledge important items in the ‘Evidence For’ column, but it’s equally important for them to summarize the main things learned in the ‘Evidence Against’ column.
Synthesizing statements don’t have to be long. But they do need to summarize the main points on both sides of the question. Don’t be afraid to have the child restate the ‘Balanced or Alternative Thoughts’ several times until the statement feels strong and convincing.
When you and the child are satisfied with the accuracy of what has been written, have the child rate the belief in this new balanced thought as a percentage ranging from 0 to 100. If the child doesn’t believe the new thought more than 60 percent, s/he should revise it further – perhaps detailing more items from the ‘Evidence Against’ column. It’s also possible that the evidence gathered isn’t yet convincing enough, and you and the client will need to work further on developing ideas for the ‘Evidence Against’ column.
If the child is capable, you may want to suggest that the child get the book “Innumeracy” by Palos from the library to check what he has to say about logic and statistical chance. This is not a math book per se, and will not be intimidating to math phobics. But it does give some examples of clearly bad evaluations of the chances of catastrophe.
Step 5: Re-rate Mood.
As part of the Thought Journal, the client has identified a painful feeling and rated its intensity on a 0-to-100 scale. Now s/he should rate the intensity of that same feeling again to see if anything has changed now that s/he has gathered evidence and developed a new balanced thought. Seeing his/her mood change can be a strong reinforcement for doing the Evidence work in the Thought and Evidence Journal. In the space of just a few minutes the child can successfully confront powerful trigger thoughts and make positive changes in how s/he feels.
Step 6: Record and Save Alternative Thoughts.
Encourage the child to record what s/he has learned each time they complete the process of examining evidence and developing balanced or alternative thoughts. Have them put this information on three-by-five file cards that they can keep with them and read whenever they wish. On one side of the file card, have them write a description of the problem situation and the trigger thought. On the opposite side of the card they should write the alternative or balanced thought. Over time, they will create a number of these cards. They can be a resource to remind them of new, healthier thoughts when upsetting circumstances might induce them to forget them.
Step 7: Practice Balanced Thoughts.
The child can use the completed file cards in a simple exercise that will give them practice with balanced thoughts. Have them start by reading the side of the card that describes the trigger situation and the trigger thought. Work at helping them form a clear visualization of the situation. Have them picture the scene; see the shapes and colors, be aware of who is there and what they look like. Hear the voices and other sounds that are part of the trigger scene. Notice the temperature. Notice if they are touching anything, and what it feels like.
When the image of the scene is very clear, have the child read their trigger thought. Try to get them to focus on it to the point of having an emotional reaction. When s/he can picture the scene clearly and feel some of the emotions that go with it, have him/her turn the card over and read the balanced thoughts. S/he should think of the balanced thoughts while continuing to visualize the scene, and continue to pair the balanced thoughts and the scene until the emotional reaction subsides.
This visualization/exposure technique may take some practice for the child in order to allow themselves to feel the emotions, particularly if the trigger thought is powerful. Assure them that you are able to help them deal with these emotions.
Return the child’s attention to the ‘Evidence Against’ column in the Thought and Evidence Journal. Look for an item that involves using coping skills or implementing a plan to handle the situation differently. Have the child circle the item(s) that suggest a plan of action. In a workbook space, have the child write three specific steps they could take to implement their action plan in the problem situation.
- If the child has more than one main trigger thought, have them do a separate Thought and Evidence Journal for each trigger thought.
- If the child has difficulty developing alterative interpretations to the trigger thought, have them imagine how a friend or some objective observer might look at the situation.
- If the child has difficulty identifying exceptions, have them think of times when they have been in the target situation without anything negative happening. Or perhaps when s/he experienced something positive. Ask – Was there a time when you handled the situation particularly well? Were you ever praised in the situation?
- If the child has difficulty remembering objective facts contrary to items in the ‘Evidence For’ column, suggest that they might enlist a friend or family member to help them.
- If the child has difficulty assessing odds of a dangerous outcome, make an estimate of all the times in the last year someone in the United States has been in this same situation. How many times has the feared catastrophe occurred?
- If the child has difficulty making an action plan, have them imagine how a very competent friend or acquaintance would handle the same situation. What would s/he do, say, or try that might create a different outcome?
- If the child has difficulty writing out these exercises, you can discuss with them and write the thoughts they give you. If you choose to do this, you must be very careful to make them do the work in terms of thinking about and coming up with the material which is to be written. You should write exactly what they say and then read it back to them for confirmation before you dispute it.