Cognitive Restructuring PDF

So we're taking a look at cognitive restructuring, which is a broad term use to look at the various techniques that we use in cognitive therapy that are designed to create a sense of cognitive flexibility or flexibility in the way a person thinks. So I'd like you to think back to the ABC chart that...

So we're taking a look at cognitive restructuring, which is a broad term use to look at the various techniques that we use in cognitive therapy that are designed to create a sense of cognitive flexibility or flexibility in the way a person thinks. So I'd like you to think back to the ABC chart that we looked at in the previous mini lecture, so antecedent belief and consequence. So the B column of that is really the automatic thought. It's their inner monologue of what they're thinking when they're in a situation that elicits an uncomfortable emotion for them. So their beliefs are the automatic thoughts. Now we ask them when they're doing that monitoring, which is usually over a period of weeks, we asked them to apply percentage. How much did you believe that thought when you had it? So when you went for coffee with your friends and you thought, she doesn't like me, I can tell how much did you actually believe that thought? So one hundred percent. Yes, I'm absolutely positive that she didn't like me or that she doesn't like me to 50 percent. Look, I'm half half on it, sort of. I think she doesn't like me, but also maybe I'm just being paranoid about it. So you apply a percentage as to how much the person believes in the thought and you ask them to do that as close as possible to the time that they actually experience the thought and write it down on their monitoring form. So later on, when it's time for us to begin the cognitive restructuring, we come back to that thought and we ask them to evaluate it. So we use Socratic questioning to try and create some doubts in the belief of the thought. So I might ask. The thought that you have that your friend doesn't like you, what is the evidence for this? What makes you think that? And so we start to try and understand whether or not the thought is a rational and objective thought of really whether it's a thought based on some kind of a distortion. So once we know what the evidence is for the thought, I might ask, well, what's the evidence? Is there any evidence to suggest otherwise that that thought isn't true? Or could there be an alternate explanation to this situation? So we've probably already covered ambiguous pictures. And so we we've got a sense that a lot of situations in life are ambiguous. So is this one of these situations that you might have jumped to that first automatic thought, but there may be other alternate explanations to consider? Is this an example of, say, overgeneralizations, you identify the cognitive distortion with the client, so similar to earlier in this module, I asked you to go back and see if you could identify your own cognitive distortions. We would do the same with a client. We do some psychoeducation on what cognitive distortions are. And together we'd work to identify some of these from their previous thought records of the past couple of weeks. And what would I tell a friend in the same situation, because we're often much kinder to others than we are to ourselves as those critical thoughts and those wild judgments that we make tend to really revolve primarily around the self than others. And then once we've gone through all of that, we really evaluate our belief in the thought. So we give it another percentage and hopefully the percentage has gone down. So whereas we might have previously believed in the thought and 80% after going through this process of questioning the thought objectively, maybe we now only believe in it 40%. So. You've had to go right now identifying distortions from your previous reflection on your thoughts, I'd like to just quickly show you now they're an example of what we'd use for this first one, these first two points here of identifying the evidence and considering whether there might be an alternate explanation. So this is an example of a table that we would use for this purpose, so we'd ask the client to write down the automatic thought, then to come up with and list the evidence supporting the thought and then the evidence against the thought. And this is the evidence. This is the area that we often don't give a lot of consideration to because we tend to just automatically believe whatever thought jumps into our mind. And so what we're doing here is trying to actively engage the client in a process of seeking evidence that refutes the thought. Now, if you remember back to the cognitive model, that's one of the reasons. One of the maintaining factors is that we are we tend to end up with evidence supporting the thought or the belief and no evidence against it. So what we're trying to do here is really get actively involved in searching for evidence against the thought to try and I guess make you thought a little less believable. Do we have an alternate thought that we could come up with an alternate explanation? And then how do we feel at the end of all of this? And what usually happens is that once the belief in the thought comes down a little bit, so does the rating of the emotion. So whereas previously anxiety might have been 50%, now maybe it's only 30% because the thought isn't a strong anymore. So what we end up with is an expansion of the ABC, so it's really important to get your head around the ABC because cognitive therapy is really just based on continually expanding that ABC. So you start off in that first session or two, giving them an ABC and they do that. They monitor for a few weeks. And then as you progress through therapy, you just essentially keep adding columns to that as part of your cognitive restructuring. So this is an example I put together earlier in the year. Actually, this I have a fear of spiders. I hate them. So this is an example from my life, so the antecedent here is I was getting ready to have friends over, which meant that I had to go outside and clean the deck. And I noticed that there were spiders living on the deck. And I just hate spiders. They invoke a real sort of fear, panic reaction in me. So my automatic thoughts, firstly eek spiders. And then I have these sort of unreasonable thoughts that come up for me with spiders that huge they have to be genetically modified spiders. And I write my belief in that 40% I know that they're probably not genetically modified, but they look really huge and I can't help that. That's a thought that comes to mind. They're all different colors. I bet they're poisonous. So I tend to think that when I've got those really fluorescent colors and they're really bright to me that just says poison. And I have no evidence to that. I've never actually looked into it. But that's just a thought that comes to my mind when I see colorful spiders. So that's 70%. I believe that one quite strongly. If I try and get rid of them, they will jump on me. That's 90%. I really believe that. And I'm not getting close to them. And they'll bite me 80%. Then I'll have a spider on me 90%. And that would be the worst. 100%. I don't think I could handle that having a spider on me. So they will really hurt me 70% and I can't deal with them 100%. So this is just this stream of thoughts that has happened from this situation. And so we would get a client similarly to write this down. Then we have our consequences, so I'm feeling fearful at 80%, anxious at 40%, and weak at 20% because I'm doubting my own capacity to deal with this situation. And so that's the emotions, the behaviors that happened. I'm embarrassed to say this. I skirted around the deck and didn't go on to it. I didn't clean it and instead I messaged a friend and got him to drive over and get rid of the spot is for me. So a real bit of a cop out there. But this is an example of an ABC of a distressing or an uncomfortable emotion. Now we expand upon that, we now have the disputation, the "D" part, disputation, sometimes called the debate of the cognitions, and this is when we start to engage in restructuring of those automatic thoughts. So let's have a look. So firstly, with the disputation or the debate, I would try and identify my engaging in any cognitive distortions here on my automatic thoughts, the result of cognitive distortions, and I can say they are I'm engaging in catastrophizing negative prediction, an all or nothing, or black and white thinking. So I'm assuming the worst. I'm jumping to the worst possible outcome. I'm assuming the only negative outcomes will occur. And it's one thing or the other, really. There's no area for there's no gray area in any of this. So I've identified that I'm engaging in some cognitive distortions and now I go through that process of Socratic questioning, of trying to consider all these thoughts objectively, or are these really sort of biased information processing thoughts? So this process of questioning, how do I know that the spiders are harmful? What evidence is there that they'll jump on me or attack me? How certain am I of the outcome? It may not be, and if it did happen, it may not be harmful and it likely wouldn't be fatal. So I start to think through this. So if it did happen, if they if the spot did jump on me, how do I know for sure that it would bite me? And even if it did, even if the worst possible thing happened, it jumped on me and it bit me and it was poisonous. Would I get through that? What are the odds that it would be a fatal spider bite? And so in a lot of situations, we really do need our capacity to deal with negative outcomes. And most people are very resilient. And even one of the worst possible thing does happen. They often tend to get through it. It may be difficult and it may be really a tough time, but most people get through the tough things in life. And so in this process, we often see that people overestimate threat or overestimate negative outcomes and really underestimate your own capacity to deal with challenges in life. So I'd probably get through it if there really no way I could deal with them and be safe. So I'm starting to dispute and debate the veracity of these automatic thoughts. And we add again, so once the client has got a sense of the disputation and the debate, and this may take a few weeks for them to really be able to internalize that Socratic questioning process and to really be able to raise doubt regarding their thoughts, we then start to look at the effect of the disputation, and this helps them with that process that we're going through this for a few weeks. And every time we do this, we go, well, what is it helping? Is the debate helping? And that's what we're trying to impart with the client. Is it this process that they're going through reduces the belief in the thought and actually makes them feel better. So at the end of that, I'm feeling fearful at 60%. So not feeling great. But it has come down anxious that 30% we get 5%. I'm feeling a sense of determination, so my self efficacy has increased my belief that the spot is genetically modified. That's gone down to 0% poisonous, 20% percent that they'll jump on me, 40% bite me 30% and so on. So you see there that the belief in the thoughts has gone down and my emotions have become less distressing. And oftentimes you only get a little bit of budge, first off. But the idea is that you do this repeatedly. You do this for multiple situations each week. You spend a lot of time on this in therapy and they do it outside of therapy. And you're just chipping, chipping away at these beliefs until they come down. And it'll take a bit of time, but eventually they do. And finally, at the end of all of that, I've disputed, I've seen that it works the F part, is there some functional new beliefs that I could have instead? This is really is there some other way that I could appraise the situation that is more adaptive? So my functional new belief here is I don't like spiders. This isn't going to be fun. But I could probably get rid of the spider myself in a way that is safe. If the spider did jump on me, it probably wouldn't hurt me. It would probably just make me uncomfortable. If it did bite me, I could get help. I've gotten rid of spiders before and it went OK. So I'm going back on some past successes here. I've never been harmed by spiders in the past, so I actually have no evidence really that these, you know, to support the danger of spiders, no personal evidence anyway. This is something I can manage. So we end up with these functional new beliefs. Now, this process from a through to if this takes time, you don't do this all in one session. This is a building of cognitive restructuring over time. So this is just another example, this is a dysfunctional thought record from one of Beck's early books. So you can see here it's Monday, the situation or the antecedent on the phone with Sarah regarding an assignment. And I'm concerned that we're on the wrong track. And the automatic thought is this might upset her. I believe at 90% she won't want to work with me now. So I feel anxious and worried. You can see the writing there in the emotion and the writing in the belief of the thought, then the adaptive response, which is the deliberation, really, or the debate I'm mind reading. So this is the cognitive distortion I've identified correctly. This does not mean that she won't want to work with me. It might even help. So perhaps she might look at it and go, hey, she's really pulling her weight. Thank God she picked up on that. Otherwise we wouldn't have done well on the outcome or the ED evaluation. I'm still a bit anxious, 60%. I told him I thought that I felt better afterwards. And if you wanted to, you could go on and then do the F to that in this particular example, because only gone to A. So a bit of a summary there for cognitive restructuring, A, B, C, D, E and F. So I won't go into that in too much detail, because we've had a few examples now. But that is a process for cognitive restructuring, bearing in mind that this is cognitive restructuring of an automatic thought. We haven't yet gotten down to that level of what goes in the B column is typically a person's automatic thoughts. And that's what we're dealing with in these early to mid part of cognitive therapy. We have another example here of an ABCDE and F so, the activating event here is I had a block of chocolate, was watching a movie at home in bed on Friday night, and the beliefs that are around sticking to a diet, breaking the diet. Now, if you remember back to motivational interviewing, I gave a few examples on dieting within that theoretical model. And it was all about ambivalence and about how people can really want change. But also change is really difficult and they get caught in that state. So, a conceptualization of this problem from a motivational interviewing point of view would be around ambivalence. But hopefully what you can see in this example is that conceptualizing from a cognitive point of view is really around the beliefs and the automatic thoughts. So the thoughts that this person has of themselves, you can see I'm a fat, lazy pig, which is a cognitive distortion of labeling, attempting to lose weight is a waste of time, which is a negative prediction. I can never stick to my diet - generalization. So you start to see that we would be working with the thoughts around dieting and the thoughts that they have around themselves rather than necessarily the process of ambivalence, although you may address that as well. But hopefully you can see the differences in how you would address that same problem with these different theoretical approaches. So I'll let you have a read through the example of an ABCDE yourself. OK, so hopefully this is giving you a few examples to understand this early process of restructuring and cognitive therapy. So early to mid, we're looking at this process, and for some people, that's all they do if they do six to 10 sessions, and that's typically about where we get to in cognitive therapy. But if they're in therapy for longer, then we might get to the underlying core beliefs, which tends to happen in the later part of therapy. So at that early part, we look we're working with that surface level, the core beliefs of things that are the running commentary through their mind. But really, if we remember back to the cognitive model, the the automatic thoughts are driven by the core beliefs as really fundamental beliefs that they hold their unshakable and they developed from early childhood and they shape the way we interpret a situation and lead to automatic thoughts and cognitive distortions. So if we've got time and if the person's and this does take time because core beliefs are a little bit harder to move, then automatic thoughts, then we'd look at working with those core beliefs. So firstly, how do we get to them? Because core beliefs are typically unconscious. So probably the most common way of getting to a core belief is what we call the downward arrow technique. And this is where we progressed from an automatic thought to a deeper core belief. And so we'd pick an automatic thought that is common for the client. It's come up in a number of the ABC they thought records or that's associated with a really strong emotion. So this particular thought makes them feel sad at 90% percent intensity. Once we've got that automatic thought, we usually right it at the top of the board or at top of the piece of paper, and then we start to question the client. And so we say, okay, so that thought that you're having, Sally doesn't like you. Let's assume that that's true for a moment. Sally doesn't, in fact, like you. What does that mean? Well, they you know, they might say, well, if Sally doesn't like me, it means that she's not my friend. Okay. And what's bad about that? OK, well, not having a friend means that I'll be alone. That's what's bad about that. I don't want to be alone. OK, and what would that say about you then if you were alone? Well, it might mean that nobody loves me if I'm alone. That would if I was going to be alone. It must mean that nobody likes me. Nobody loves me. Right. So in a sense, we're getting to a place where. If that were true, you would be unlovable, if no one loves you, then I guess putting that back to what that means about you would be that you are unlovable. And so you use this process of questioning and it often takes more than sort of three questions and you might use some of them more than others, and you might just do a series of if that's true, what would that mean? If that was true, what would that mean? So you carefully construct those questions to try and continually move down to from a specific, narrow, automatic thought to broader and broader beliefs that come that are underneath that thought until you finally get to the core belief, which is the global statement usually about the self. So I am unlovable. Is that global concrete statement about the self? So that's what that's what the downward arrow is, and usually at each question, you then put a little arrow and so Sally doesn't like me and you do an arrow and you say, if that's true, what does that mean? And they say, well, it means I don't I wouldn't say she's not my friend. So you're right. She's not my friend, OK? What's bad about her not being your friend for another hour? So you write the responses in between each arrow facing downwards. And so that's what's called the downward arrow technique, is that those downward arrows in between each client response eventually getting closer and closer until you get to the core belief when you stop. So you've got another example at the bottom there of that downward arrow technique, C for client, T for therapist, but that process of questioning to get at the underlying core belief. Once we've identified the core belief, then we start to challenge it. So the aim is to develop a more balanced belief system. So core beliefs clients typically believe in them 100% percent or pretty close to and it can be really distressing for a client to be confronted with their core belief. You can imagine if you have a fundamental belief that no one will love you, that you are unlovable, or that you are a failure. That's a really awful thing to be confronted with, to hold about yourself and to believe what can be quite distressing and quite challenging for the client. And so you need to be really sensitive of that and give clients adequate time to process the core belief and to reflect upon it and to discuss those experiences before you move into challenging it. So you need to give the client adequate time to process before you go into challenging. When you do go into challenging, then you start again that Socratic questioning. Are there any experiences that you have had that would suggest that that belief isn't true 100% of the time? So if the belief is I'm a failure, are there any experiences or successes that you've had that would suggest that that belief is not 100% true? And so you end up with a maladaptive belief becoming a more balanced belief, so, the maladaptive belief, for example, being no one will ever like me or I'm unlovable or unlikable, the balanced belief would be not everyone will like me all of the time, but I will be quite likable to some people. So we're not going for a positive belief here. This is different to, you know, you get those Mount Franklin water bottles and they say think positive. If only it were that simple. We're not talking about just changing to a positive belief. We're trying to make things balanced and give clients a sense that things weren't going right all of the time. But they'll go right enough of the time for them to have a meaningful life. We can also do behavioral experiments to test the belief and I'll show you an example of one of those on the next slide and cognitive continuum work, which is where we essentially lay out a scale on board a piece of paper from zero to one hundred. And we get the client to describe the belief in absolutes. So the belief is I'm a failure. What would a person who was 100% of a failure look like? What does a person who is 0% of a failure look like? And then you fill in the gaps in between and you get them to write where they are. And usually what that means by the time they do that, they realize that they're not 100% of the value. They sit somewhere in the middle, as we all do. And so we're trying to again, same as with the automatic thoughts, just continually chip away at how much they believe these core beliefs, but that the core beliefs often take longer in that process of chipping away at them. This is an example here, a behavioral experiment, so behavioral experiment is an experiment that we set out with a client that's really specific and testable and aimed to essentially collect evidence against the core belief. But to clients, it's really about testing that core belief. So here the core belief is I'm fundamentally unlikable. We set up an experiment collaboratively. And so the experiment in this instance is that the person will make a point of saying hello to people at university. And the prediction based on the core belief, what the person believes will happen is people will ignore me because they're not a likable person. Now, when you set up these behavioral experiments, the key is you need to be really specific with the client about what would be the evidence that would support the core belief and what would be the evidence that wouldn't support the core belief, because unfortunately, they can go into these experiments and just everything is seen as evidence supporting the core belief or they dismiss evidence against it. So you need to set that up really early on and then they document what actually happened. So one person ignored me, but I did mumble. They might not have heard me. Two people smiled at me. Four people said hello back. And one person from my tute asked me how I was. And so we can check for that then with the client, so firstly, the prediction didn't happen. So we didn't we don't have evidence that supports that core belief that you hold. And in actual fact, what did happen, we could probably interpret as evidence against the belief that there is some part of you that is actually likeable to other people. And so we bring this back then to the cognitive model and work with the client about how when they hold a core belief, it leads to this style of thinking and eventually this way of behaving. That actually results in greater evidence to support the core belief and no evidence against it, but if we act, if we thought in different ways, if we acted in different ways, we'd get different outcomes. So taken together, this is how we'd go about restructuring it by the automatic thought level and the core belief level over a period of time.