Cognitive Behavioural Therapy

Lesson 6

Dealing with Negative and Distorted Thought Processes

The Socratic Method

Assumptions and Beliefs

Dealing with Negative and Distorted Thought Processes

All individuals have a natural leaning to think in a certain way about certain
things and it is this that makes us who we are and establishes certain aspects of
our personality and how we interact and contribute to the people and
environment around us.

Some individuals find it natural and easy to have a positive and optimistic
outlook on life wherein some others are more prone to considering life more
cautiously and with a far more measured view.

And then there are some, for whatever reason will always see life through
pessimistic and negative eyes.

The reasons for the way that an individual will think about their life can be
governed by a variety of different factors and these include:

Biological

Genetic Inheritance

Environment

Peers

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Peers Expectation

Upbringing

Adulthood

Positive and Negative Life Experiences

As part of the CBT therapist‟s role, they need to support the client in seeing that
although they cannot change their past and how it has fashioned them into
viewing their life, they can certainly change the way in which they view
themselves, their environment and their life.

In the same way many of the thoughts the client has are actually not really
helping them but playing a very large role in hindering them. They need to be
made aware of the fact that the role of CBT is not to find the positive way of
considering an experience, a thought process or presenting issue but more as a
way of finding the alternative ways of thinking and perceiving and addressing
the situation.

Bearing this in mind, we will now look at Negative Automatic Thoughts or

(NATS).

When NATS are discussed within a CBT context, the term refers to the
pessimistic, disempowering thoughts that everyone is capable of producing at
some point in their lives.
e.g.: „I feel stupid‟, „I cannot cope‟, „I always fail‟.

These types of thoughts tend to make the individual experiencing them even
more depressed, anxious or stressed and can easily put a client into a negative
downward spiral.

These NATS tend to be unrealistically pessimistic and focus upon complete

negativity and normally appear to come from nowhere and almost
„automatically‟ spring into an individual‟s mind at any given point, frequently
without any warning.

NATS can be frequently described as „an internal voice‟ or „internal talk radio‟
that cannot be turned down or off.

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By their very nature, it appears to the client that the more they try and turn the
thoughts off, the more stubbornly and persistently they remain.

Whilst I would not suggest that to understand a NAT you should experience
one, I would suggest that you use this experiment listed below to feel the effects
of a stubborn thought or image that will not leave.

Sit down somewhere quietly for a few minutes.

Now during this quiet time you may think of absolutely anything, anything at
all, except a large pink elephant, do not, under any circumstances think about or
picture a large pink elephant.

What did you think about?

What did you picture?

The likelihood is that your mind was suddenly filled with pink elephants and the
harder you tried to block the thought, the more stubbornly it remained.

Also the likelihood is that up until the point of this experiment, you had not
given much thought to a pink elephant today or probably for quite some time.

So, why did you experience that thought once I had requested that you did not
think about it?

Basically, once an individual places a meaning to a thought and then tries to

block it out, no matter how hard they try, the thought will appear to increase in
size and strength.

Normally, when you have a thought that you deem of no great importance, it
will enter your mind, remain briefly and then you will quickly begin thinking
about something else.

This is one of the very important concepts within CBT. The process is not
about controlling the thinking process and continuously blocking out negative
thoughts in any shape or form but taking a serious look at the validity of the
thoughts and learning how to re-evaluate them, by seeking more rational and
focused alternatives that will serve the client far better than their previously
irrational distorted thought processes.

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For the client to become aware of these negative thoughts that they are
experiencing, they need to be able to identify a NAT when one is in play.

Below is a list of characteristics that all NATS share in some shape or form.

They are disempowering

They are unhelpful

They are frequently untrue

They appear to be easily believable

They come to mind very easily

They frequently appear without any warning

They frequently appear without any trigger

They can be virtually impossible to stop or remove

They keep the person experiencing them depressed or anxious

They make it very difficult for the person experiencing them to make changes

Whilst the client needs to be able to recognise a NAT just by the effect they
have upon the client, another proven CBT method is also the use of a thought
record.

Most clients tend to find that in the early days of treatment, filling in thought
records can really be quite difficult and time consuming. They find they have to
work hard at focusing upon a particular thought to prove or disprove its validity,
but as time progresses and they are more practised at the task, it almost becomes
second nature to them.

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Below is an example of a thought record worksheet which is frequently used

within CBT practices.

What How did you What did Alternative How do you

Happened? feel? you think Thoughts feel now?
when this
happened?

What were How did you What exactly What more How far do
you doing or feel? were your positive or you still
thinking thoughts at alternatives believe your
about? the time? to your negative
negative thoughts?
thoughts can (%)
you think
about?
How bad How far did Do you feel
would you you really any better
rate it (%?)? believe emotionally
them? (%) or mentally
now? e.g.: I
feel less sad,
less angry,
Try to list as less tearful
many as (%)
possible?

How much
do you
actually
believe each
one? (%)

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Below is an example of a completed thought record used within CBT.

What How did you What did Alternative How do you

Happened? feel? you think Thoughts feel now?
when this
happened?

What were How did you What exactly What more How far do
you doing or feel? were your positive or you still
thinking thoughts at alternatives believe your
about? the time? to your negative
negative thoughts?
thoughts can (%)
you think
about?
How bad How far did Do you feel
would you you really any better
rate it (%?)? believe emotionally
them? (%) or mentally
now? e.g.: I
feel less sad,
less angry,
Try to list as less tearful
many as (%)
possible?

How much
do you
actually
believe each
one? (%)

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I went away I felt really I will not be I need a I coped well.

to a Spa for anxious and able to cope break away I did get a
a few days panic filled. somewhere I from things bit jittery but
with some do not know (70%) my sister
friends and I was really (100%). helped me
family. afraid about It will be through it.
being I will have lovely to
somewhere I one of my spend some I did not
did not panic attacks relaxed time have a full
know. and pass out with my panic attack
Anxiety through friends and
(95%) terror (95%) family I did not get
Panic (100 (100%) taken ill.
%) I will get
Fear (90%) taken ill If I do have I had some
there and a panic really great
have to be attack, my Spa
taken away sister who treatments.
in an will be there
ambulance is a nurse I feel much
(90%) and can help more relaxed
me if I need and calm
it (85%) after my
break away.
I feel really
good (100%)

The process of using a thought record is not to eliminate the NATS by

attempting to control the thought process or by blocking out the notion. As we
have seen, that tends to cause the NAT to multiply and worsen. But by allowing
the NAT to come and then to become invalidated by choosing a more balanced
and believable alternative.

As the newly discovered positive thought processes become more readily used
and stronger, they will gradually become the client‟s default thought setting as
opposed to the NAT and due to this, the NAT will become less powerful and
believable and they will eventually fade away of their own accord as they are no
longer used or required.

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As part of the CBT process, it is a valuable part of the therapy for the client to
not only focus mentally but to record their negative thoughts and feelings,
keeping track of them and constantly examining them to check out their
validity.

If the client discovers the thought to be unhelpful or negative, then they will
need to be able to challenge that thought with what is called „a balanced
response‟. This is a reply that can be used against the negative disempowering
thought that is based upon firm provable evidence.

The client may not always find it easy to rationally evaluate their thoughts and
responses and find positive alternatives but by asking the right questions the
client definitely has to face the thought and look at it from other directions. In
this way they will normally find it achievable.

Below are lists of sample questions that can be used to find ‘a balanced
response’.

Is this thought actually true?

Can I prove it is true?

How can I prove that it is true?

Could I look at this in another way?

What would those people in my life that love and care about me say about this
thought?

Would they be able to find any relevant evidence to prove that this thought was
true?

If someone I loved or cared about had this thought, what would I say to them?

Am I actually blaming myself or feeling guilt over something that is not actually
my fault?

Am I actually jumping to conclusions regarding this thought or situation?

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What I have previously learned from situations that would help me now?

Am I completely 100% certain that this is the truth of the situation?

What are the positives and strengths that I possess that I could use regarding this
situation?

When I felt like this previously, how did I react, behave or think?

When I am not feeling as I do now, would I handle this situation differently?

Have I had other experiences that may suggest or prove that this thought is not
completely true or real?

Sometimes NATS are not always invalid and completely negative but there, as a
warning or protective function.
e.g.: A client who frequently takes time off work, does not work at all whilst at
work and constantly puts their manager down in front of others may, after
several disciplinary warnings have the thought that they will probably have their
employment terminated.

As the client is having a thought that is rather negative, there is basis to the
thought and the likelihood that it may well come true.
The thought is apparent to the client as a warning sign not just to disempower
them.

Sometimes, trying to locate a positive alternative thought may be almost

impossible to the client and when this occurs, frequently a CBT practitioner or
therapist will suggest that the client just acknowledges the thought or situation
that they are having or are in and use a simple direct coping strategy instead.

Below are some examples of relevant coping strategies statements that may
be used.

I am going to change how I feel.

I will feel calmer and far more in control if I can see the positive aspect of this.

I have been in this situation before and have survived and so I will again.

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I know that things will improve generally when I am more capable of dealing
with my problems.

I know that the more I worry about the situation that the worse it will appear.

I am strong emotionally and I can handle my feelings in all situations.

I am proud of just how far I have come and I know that I can improve even
more.

Whilst this feels like an uphill battle, the important thing is keep focused and
continue building up my confidence/self belief/ happiness.

I will face this situation and I will continue to practice my coping skills and
strategies.

It is worth remembering, as with all things, practice really does make perfect
and the more a client is able and willing to practice their ways of thinking in a
more focused and balanced manner, the easier and more natural it will become.

By positively focusing and preparing to enter a worrying situation and deal with
the NAT that will be there and that will have a negative impact upon the client,
they will be prepared to react with a more balanced and realistic response and
from this feel much more in control of the situation.

The Socratic Method

Within the CBT process, the use of open questioning that aims to actually guide
discovery towards the solution for a problem or presenting issue is known as
„The Socratic Method‟ or „ Socratic Enquiry‟.

It is named after Socrates, who was a famous Greek philosopher who lived in
Athens in 400 BC.

Socrates was famous for his ability to question and to use enquiry and in so
doing was able to encourage and support his students to reach conclusions
regarding their worries and concerns without him directly having to instruct
them to do so.

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The use of personal open questions that force a considered and thought
provoking answer is a valuable tool within the CBT process and are frequently
used when a client presents as needing to understand and resolve an emotional
or physical presenting issue.

Within CBT, the use of Socratic Enquiry internally, i.e. in the client‟s head,
spoken verbally to the therapist or into a mirror or recorded in the CBT
workbook are all encouraged and used as part of the client‟s homework and
assignments.

The value of the Socratic Method or Enquiry is that it encourages the client to
give consideration to certain aspects of their presenting issue that they may well
have overlooked.

It basically works on the understanding that the client has a vast store of
valuable information that is known to them but just „outside of their awareness‟.

This information tends to be overlooked as it is not normally directly to hand

when a client is mulling over a problem or difficulty.

By using the conscious and subconscious together and in a focused manner the
client is allowed to weigh up the issue in a more balanced and logical manner
than just going by gut reaction or habitual response to a situation.

The beauty of The Socratic Method is that it uses very basic simple questions to
bring to the surface often very complex thoughts, awareness and answers by the
client.
It links the factual information that a client has to the abstract interpretations
they may well have and then causes them to draw a relevant conclusion from
their dual assessment.

Below are questions that are frequently used within The Socratic Method.

How do I feel?

How did I feel?

What is my reaction?

What was my reaction?

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What went though my mind when this was happening?

Have I any relevant evidence that will support this thought?

How do/would other people deal with this situation?

Have I any relevant evidence that would completely or partially invalidate this
thought or issue?

Does this have a personal meaning or perception to me?

What else do I currently know about this situation/thought?

How might I advise someone else who was in this situation?

How else could I look at this situation? (Positive and Negative thoughts to be
addressed equally).

What other conclusion could I now take from the extra information and
thoughts I have on this situation?

Ideally, the client is actually hunting for answers that will encourage and
support them in exploring the situation at a greater depth and from that is able to
change their concept of the presenting issue.

Assumptions and Beliefs

It is essential for therapists to understand how beliefs are created and the impact
that they have upon themselves and their clients.

With this understanding and personal experience, the therapist can perform at
their very best and therefore prompt the best successes, changes and therapeutic
growth from their clients.

Without this knowledge and understanding, a therapist can and will waste
valuable time trying to work on areas that are controlled primarily by a client‟s
fundamental beliefs.

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A client‟s beliefs are forming from the moment they were born.
This began with people smiling or shouting at them when they were a newborn.
These early interactions and all other subsequent interactions with other human
beings thus formed the person that they are.

The client has created an image of themselves that is based on the attitudes of
other people.
It is an image that they foster that can either help or hinder the full development
of their entire potential and it never remains static but changes with every new
situation or circumstance.

From birth, “experts” have watched, formed opinions and evaluated everything
that the client did. These so-called “experts” were parents, teachers, relatives
and elders and as the client grew up; they accepted and valued their opinions as
the truth.

Now, at adulthood, the client has the ability to evaluate whether these people
were actual experts concerning their abilities.
In different ways, they would have aided and limited the client‟s development.

An adult human being will operate within the limits of their self-image and
eventually that perceived image becomes the real person as opposed to just a
concept.

Eventually it becomes the “norm” and the “comfort zone”, where the individual
feels safe, secure and protected. Whilst this sounds a positive notion a comfort
zone can become a negative place to stay as it can end up as a limiting prison.

As soon as the client makes the decision to change, they suddenly have the
actual freedom to choose and thus enjoy empowering beliefs and behaviours.
The process is the same for all human beings.

A person‟s self-image and their ability to assume is a general accumulation of

every attitude and opinion that they have been told about themselves since they
were born, and in some cases, pre-birth.

It becomes so ingrained by reinforced repetition that it eventually becomes the

subconscious picture of their self-belief.

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It is the concept that who the client thinks they are and who they believe they
are that actually determines how they respond to life and therefore what they
believe they are capable of achieving.

This comfort zone is the life that a person feels comfortable living. In some
cases, it may be a life full of poverty, fear, pain, drudgery and sadness.

People will remain locked in these situations because their self-image and belief
systems support them there. They truly believe that this is what they are worthy
of or truly deserve and safe in this knowledge, they remain locked within this
„comfort zone‟.

A person lives within a closed personal loop.

The self-image is created by the personal belief system (what a person believes
to be true about them).
A person builds and feeds these beliefs and actually feels comfortable with
them.
This loop has three components a) how a person behaves b) how a person self-
talks and c) a person‟s picture of self-image.

Thus, as a client moves from one to the next, they reinforce and strengthen each
stage so it becomes a never-ending circle.

The therapist‟s beliefs can be changed; therefore the client‟s beliefs can be
changed.

It is worth remembering, that a client chose to believe their own beliefs;

therefore they can choose to change them.

Socratic enquiry is also used within CBT to challenge assumptions and beliefs
and as before this is done by the client asking themselves simple questions that
they are required to answer either verbally or in their workbook for further
reflection.

Below are some example of questions that could be used to challenge a

client’s beliefs.

How helpful or empowering is it for me to continue to have this belief?

What are the advantages of having this belief?

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What are the disadvantages of having this belief?

If this belief is completely true, how would other people deal with it?

What relevant evidence do I have that this belief is actually true?

What relevant evidence do I have that states that this belief is not actually true?

This line of open questioning gives the client the chance to remove their
disempowering belief and the ability to find better more appropriate
alternatives.

The other main aspect of Socratic enquiry within the CBT process is that it is
not just used to change a client‟s mind or perception of a situation or presenting
issue or thought. It also allows the client to actively explore alternative options
to how they think, feel or behave in a given situation. Whilst they may not have
fully given up their disempowering thought, they are more aware of more
positive and empowering ways of being that they may well use in the future
when they feel ready to do so.

© Sue Etherden 2008

The right of Sue Etherden to be identified as the author of this work has
been asserted by her in accordance with the Copyright, Designs and
Patents Act 1988.

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QUESTIONS ON LESSON SIX

Q1. What is your understanding of The Socratic Method?

Q2. What is The Socratic Method also known as?

Q3. What is your understanding of a ‘balanced response’?

Q4. The reasons for the way that an individual will think about their life
can be governed by a variety of different factors and these include?

Q5. Define NATS?

Q6. Give 3 examples of a NAT?

Q7. Design a thought record that could be used with CBT?

Q8. Explain your understanding of how a belief system is created?

Q9. Who was Socrates and what was he well known for?

Q10. Give 5 examples of relevant coping strategy statements that could be

used within CBT?

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