CBT skills

CBT skills

CBT top tips for clinicians!

I'd love to pass on reviews of workshops, books, research, and focus on the material that's clinically useful. It would be great if you could take away a new idea or technique that you could use straight away with your patients.

Ian Evans ‘How and why thoughts change’ book review

This might help your patients.Posted by Philip Kinsella Tue, November 17, 2015 23:56:04

Ian Evans

‘How and why thoughts change’

This is a tremendous book looking in detail at a common treatment strategy for CBT therapists. It is interesting and humorous. I would have liked a little more on how emotion influences thinking, and perhaps more guidance on choice points about which approach or technique to use at a particular moment

Here is a rough summary of relevant content:

Thoughts are real and relate to actions. Thoughts have the potential to influence moods, and vice versa. We can have meta-cognitions, thoughts about thoughts e.g. ‘My mind is out of control.’

A range of psychotherapies tries to influence thoughts, including CBT. However, it may be that CBTs do not work by changing thoughts, but by other processes in the therapy e.g. the relationship, or behavioural change. Therapy can both target the way information is processed e.g. worrying cycles, and how thoughts are retrieved from memory (problematic in PTSD), and the overt conscious thoughts that arise from such processes (‘no one at this party likes me’). The processes can be addressed by bias training e.g. the person who thinks no one likes him can be trained to focus on friendlier people, perhaps through a computer programme.

Schemas, more ingrained mental structures, e.g. about your mother, may be a mixture of expectations, assumptions and emotional connections. These may not be clearly articulated, and be out of awareness, or only articulated when specific questions are asked (‘how did you get on with your mother?). Beliefs and schemas have a degree of inertia, and won’t change easily.

Thoughts are kept in memory, of which there are three stages: encoding, storage and retrieval. Implicit, explicit and autobiographical memories are important.

External cues, internal search strategies, motivation, mood, and associations will access thoughts and memories. Thinking involves problem-solving, decision-making reasoning and creativity.

There are two thinking systems: fast and slow described in Daniel Kahneman’s book. System one functions automatically to notice and allow rapid reactions to day-to-day urgent problems. System two functions with mental effort (so is less likely to be used), and is the conscious reasoning self. System two can take over from system one, but there may have to be a decision for this to happen.

Thinking can be influenced by mood, personality traits and social influences.

Thoughts that depressed patients may utter such as ‘I’m a terrible person’ may function to elicit sympathy and support.

Rumination, brooding and worry can be a problem.

There can be distorted thoughts, delusions and dissociation, also obsessional thinking.

Kahneman identified judgment heuristics. Number one is representativeness, taking one thing to represent the general. Number two is availability; this means how easily examples can be brought to mind. Number three is anchoring, the initial base rate influences the final estimate.

Do thoughts influenced mood or vice versa? Both are true. Words can become associated with feelings so the word ‘fail’ may become associated with low mood and easily evoke it.

State dependent retention is important and means recall of an event is better if during recall one reinstates the mood one was in during their original learning. Also there is the mood congruity effect: people are more likely to attend to events that match their emotional state of the time (p137).

Emotions can be seen as providing information.

There are basic emotions: fear, anger, sadness, and happiness. Some emotions are more complex and are influenced by cognitive appraisal e.g. jealousy and embarrassment.

It is simplistic to separate thoughts, feelings and behaviours as they interact together.

There are general principles of how and why thoughts change:

This can be external influences e.g. psychotherapy or friends or information, or internal, something the person does for themselves (‘I’ll challenge my thoughts’).

Therapeutic change is influenced by the quality of the relationship, also by changes the therapist recommends to the patient.

Therapists ask specific questions to challenge the patient’s thoughts. New experiences that can be planned with the therapist (exposure or behavioural experiments) reinforce this. Sometimes an epiphany happens that brings about a profound change; this could be an event or something that’s said.

It is important to remember that specific thoughts occur in triggering social situations.

Metacognition is an important perspective. ‘Thoughts don’t matter, but your response to them does’.

Ideas to enhance CBT practice:

Try to enhance positive affect at an earlier stage to increase cognitive flexibility.

Also increase motivation to do the work.Improving your therapeutic relationship encourages change. Patients and therapists may have dysfunctional schemas about therapy that need exploring. Could explain the idea of fast to slow thinking.

Therapists should use Socratic Discovery rather than arguments.

Use a thought record.

Evaluate the function of thoughts: thoughts may be a type of behaviour “If I say I’m sad he’ll be more supportive’.

Be aware thoughts can be general, for example ‘I’m unattractive’ or more specific ‘if I put on weight I’m unattractive’.

Sometimes listening and reflecting works better than challenging.

Consider closed-mindedness-this may be to protect the patient from emotional threats. ‘A man convinced against his will, is of the same opinion still’. Patients may have beliefs that make them reluctant to consider alternative opinions.

Good question is ‘what would you say to a person who said…’

Help the patient see that her narrative of her life is unhelpful

Help the patient change harsh words to neutral words for example ‘I’m weird’ to ‘I’m a character’.

Help the patient to be self compassionate and accept their flaws: this could be a compassionate image, or they could write a compassionate letter to themself.

You can change a thought by changing the frequency of its occurrence (manage triggers); changing the content; change its value: ‘I don’t mind this’; changing the process of reaching a conclusion (just because I’ve done poorly in this job does not mean I’m a failure; change the relationship with the reinforcer.

The book’s conclusion is addressing thoughts is valid in therapy. It is not certain which the best techniques are, this may have to be judged at the time of the interaction, bearing in mind evidence based protocols. The devil may be in the detail of the technique!

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