Skip to main content

7. 识别来访的想法

CHAPTER 7 Identify Your Clients’ Thoughts Did you have a chance to do the homework from the last chapter? Here is one of my catastrophizing cognitive distortions that I caught. I am in the car, driving to a meeting with colleagues I don’t know very well. I pick up coffee, and within five minutes I manage to spill a good part of it on my new white shirt. Can you guess my thoughts? I will look like a complete idiot; everyone will think I am totally incom- petent. However, the truth is I simply pulled my jacket over my shirt—and it wasn’t great, but it certainly wasn’t a catastrophe. Were you able to catch any of your own cognitive distortions? Were you able to identify your clients’ thoughts about self, others, or the future? If you did the homework, take a moment to reflect on what you learned. If you did not do the homework, think about an upsetting experience that happened last week. Identify your thoughts and then ask yourself, Do my thoughts contain unrealistic judgments about self, others, or the future? Are they a cognitive distortion? Set the Agenda In the last chapter we focused on how to decide which thoughts are worth working on. Now that we know what to look for, it’s time to get our hands dirty and learn how to look. Agenda Item #1: Identify automatic thoughts. Agenda Item #2: Helpful questions. Agenda Item #3: Your clients’ images. Agenda Item #4: Additional strategies to identify thoughts. Agenda Item #5: How do you know which questions to use? Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior.

Work the Agenda Remember that the purpose of identifying your client’s thoughts is to understand what a situation means to your client, or how he interpreted the situation. We want to help our clients identify their hot thoughts. To recap, a hot thought explains your client’s feelings and behavior and is an unrealistically negative evaluation of self, others, or the future. Clients can have a variety of reactions when they start to identify their negative thoughts. Many clients feel more in control when they understand what is maintaining their difficulties and can iden- tify the relationship between their thoughts, feelings, physical reactions, and behaviors. Other clients become more distressed when they realize how negative their thoughts really are. It is important to explain that even though it can be hard to look at negative thoughts, it is a first step to feeling better. Agenda Item #1: Identify Automatic Thoughts It sounds simple, but if you want to know what your client is thinking, just ask. The following “Just Ask” questions are often all that you need. “Just Ask” Questions General Probing Questions • What were you thinking? • What were you saying to yourself at the time? • What was running through your mind? Prompting Questions • Any other thoughts? • Anything else? Reflective Statements • So you were thinking…(repeat last thought) Often just repeating the last thought or statement will encourage the client to elaborate on more thoughts. You can then choose to add a prompting question. Clarifying Questions • Can you tell me more about that thought? When you ask your client, “What were you thinking?” use a gentle, curious tone that encourages self-reflection. It is often helpful to refer to the situation you are exploring. For example, Suzanne’s therapist asked, “When you received the invitation to the barbecue, what were your thoughts?” Don’t forget to go slowly and give your client time. It can take a couple of questions before your client can identify his thoughts. Let’s look at the example we started working on with Suzanne in chapter 5. If you remember, the principal of her new school invited her to a barbecue with the other new teachers. You know about the situation (invitation to the barbecue), you already know her feelings (nervous, worried, and embar- rassed), you know her physical reaction (clenched stomach and tense shoulders), and you know her behavior (put the invitation aside and did not respond). You now want to identify Suzanne’s thoughts, and in particular you want to help her identify her hot thoughts. Let’s see what happens if her therapist uses the “Just Ask” questions. Therapist: Suzanne, you have done a good job identifying your feelings, physical reactions, and behav- ior. Let’s see if we can also identify your thoughts. When you were invited to the party, what thoughts went through your mind? Notice her therapist starts by positively reinforcing Suzanne for identifying her feelings, physical reactions, and behavior. She then refers to the situation before asking a general probing question. Suzanne: (pausing) I don’t know, just that I don’t want to go; the other new teachers will all be there. The thought I don’t want to go is the behavior Suzanne wants to do. It is a fact. The thought All the other new teachers will be there is also a fact. These thoughts do not contain unrealistic judgments about self, others, or the future; they do not explain her feelings; and they do not contain a cognitive distor- tion. Suzanne has not yet identified a hot thought. Therapist: Any other thoughts? The therapist uses a prompting question. Suzanne: Well, just that I won’t fit in. Suzanne is starting to identify her hot thoughts. I won’t fit in is a thought about self. Her therapist wants to keep exploring. Therapist: Are there other thoughts that go with I won’t fit in? The therapist uses another prompting question. Suzanne: I feel that I will just stand there looking awkward, and no one will talk to me. I will be so anxious, and I will probably get all sweaty. This is an example of a client using “I feel,” when what Suzanne really means is “I think.” When this happens, simply repeat the sentence saying, “You were thinking,…” Therapist:You were thinking, I will just stand there looking awkward, no one will talk to me, and I will probably get all sweaty. Suzanne:That’s right, it’s not just that they won’t talk to me, it’s that no one will want to talk to me. At this point Suzanne has identified a thought about herself: I won’t fit in; thoughts about herself and the future: I will stand there looking awkward, and I will probably get all sweaty; and a thought about others and the future: no one will want to talk to me. Her therapist then asked Suzanne if she would like to write down her thoughts on the Understand Your Reaction worksheet. Sometimes clients like to write, and sometimes they like me to write. I don’t think it matters. If I am writing, I repeat my client’s thoughts out loud as I write. I find that this encour- ages my client to start thinking about his thoughts, rather than just experiencing them. Let’s see what Suzanne’s worksheet looks like. Understand Your Reaction SituationFeelings (Rate 1–10)Physical Reactions (Rate 1–10)BehaviorsThoughts What? Who? Where? When?What did I feel?How did my body react?What did I do?What did I think? Principal invited me to barbecue with the three other new teachersNervous (7)Clenched stomach (4)Has not responded• I don’t want to go. Worried (8) Tense shoulders Embarrassed (6) (5) • The other new teachers will be there. • I won’t fit in. • I will just stand there looking awkward. • No one will want to talk to me. • I will probably get all sweaty. Agenda Item #2: Helpful Questions Sometimes when you ask your clients what they are thinking, they respond with thoughts that are not hot thoughts. For example, Raoul felt very awkward going to the lunchroom. When his therapist asked what he was thinking, he responded, “I don’t know, I just feel awkward.” His therapist needs to ask additional questions to help Raoul identify his thoughts. WHAT DOES THE SITUATION MEAN TO YOUR CLIENT? One way to discover what a situation means to your client is to ask him directly. You can use any of the following questions: •What does this situation mean to you? •What does this situation mean about you, other people, or the future? •What is it about this situation that is so distressing for you? • How is this situation a problem for you? Initially, I felt very awkward using these questions. My clients had just told me about an emotion- ally difficult situation, and I was asking what it meant to them or why it was a problem. However, I have consistently found these questions to be very helpful. Like all questions, it is important that you use a gentle, curious tone that conveys your desire to understand your client’s experiences. Let’s go back to Suzanne. Her therapist decided to keep exploring, using the additional questions identified above, in order to be sure she fully understood why Suzanne found the invitation to the bar- becue so distressing. Therapist:I want to be sure I understand what it is about the invitation to the barbecue that is so distressing for you. Suzanne:It’s not the invitation, it’s going there with all the other new teachers. Therapist:What is it about being there with all the other new teachers that is so distressing for you? Her therapist uses one of the questions to keep probing what the situation means to Suzanne. Suzanne:It’s hard to figure out. I guess that I won’t fit in; (pausing) I think my biggest fear is that they won’t want to be my friend. Therapist:Sounds like the big fear is “they won’t want to be my friend”? Suzanne:That’s right, that no one will want to be my friend, and I will be there all alone. In the example above, the question “What is it about this situation that is so distressing for you?” helped Suzanne figure out her underlying thought. Let’s look at another example and see how you can use these questions. Your Turn! What Does This Situation Mean to Suzanne? In her fifth session, Suzanne wanted to focus on her feelings at recess. She was increasingly anxious and uncomfortable during recess duty and had been trying unsuccessfully to avoid it completely. Her thera- pist asked if Suzanne could give an example of what happens. Suzanne explained that she stands alone in the schoolyard, does not talk to anyone, and tries to look as if she is supervising the children. She feels very lonely and wishes the other teachers would talk to her. Suzanne adds that this exact situation happened yesterday. Her therapist believes this is a good situation to work with. She knows Suzanne’s feelings (anxious) and her behavior (she stands alone). She wants to understand Suzanne’s thoughts. Therapist:When you are standing in the schoolyard at recess, what are you thinking? Suzanne:(looking sad) None of the other teachers are talking to me. Suzanne’s thought is a fact. It does not indicate what the situation means to Suzanne. Look at the three possible responses below and pick the one that will help Suzanne identify what the situation means to her.

  1. Help me understand what it is about the other teachers not talking to you that is a problem for you.
  2. Have you tried talking to them?
  3. What do you feel when the other teachers don’t talk to you? Response #1 is the best answer to help Suzanne identify what the situation means to her and to help Suzanne identify her hot thoughts. Response #2 starts problem solving, and response #3 takes therapy into a different direction. Therapist: Help me understand what it is about the other teachers not talking to you that is a problem for you. Suzanne: The main problem is that I stand alone, while all the other teachers stand with a friend and talk to each other. Look at the three possible responses below. Choose the response that will help Suzanne explore what the situation means to her.
  4. When the other teachers don’t talk to you, how do you feel?
  5. What does it mean to you that you are standing alone, and the other teachers are standing with a friend and talking to each other?
  6. When you say the other teachers don’t talk to you, how many other teachers are outside at recess? Response #2 is the best response to explore what the situation means to Suzanne. Response #1 would be a good response if you wanted to identify her feelings, and response #3 would be a good response if you wanted to understand the situation. Therapist: What does it mean to you that you are standing alone, and the other teachers are standing with a friend and talking to each other? Suzanne: It means that the other teachers don’t want to talk to me, because none of them approaches me. At this point, Suzanne has identified a hot thought that explains her distress at recess. Her hot thought The other teachers don’t want to talk to me is a thought about others. Her therapist could con- tinue using the “Just Ask” questions and the questions about the meaning of the situation to explore whether there were other hot thoughts.

WHEN THE SITUATION INVOLVES ANOTHER PERSON Many difficult situations involve other people besides your client. It can be helpful to ask what your client thinks the other person’s behavior means about how he or she thinks or feels about your client. For example, in Suzanne’s situation, her therapist asked, “What do you think the other teachers not talking to you means about how they feel toward you?” Suzanne responded that she thought it meant that they did not want to get to know her and liked to stay in their own little cliques. A good follow-up question is whether there is anything about your client that causes the other person to behave in this manner. For example, Suzanne’s therapist asked if there was anything about her that would cause the other teachers not to include her. Suzanne responded that she was shy and awkward and would not fit in. Go to College Exercise 7.1: (a) Yonas Asks a Question, and (b) Diana Wants to Practice identifying what situations mean to your clients. FOCUS ON FEELINGS Another approach to exploring your client’s thoughts is to ask what thoughts go with specific feel- ings. I often use this approach when my client is very aware of his feelings but is having trouble identify- ing his thoughts. There are a number of ways I ask what thoughts go with my client’s feelings. I have used these ques- tions to explore a great variety of feelings, including sad, hurt, annoyed, disappointed, angry, and anxious. I often ask my client to take a moment, go back to the situation in his mind, and focus on the feeling. I then ask one of the following questions: •What thoughts go with this feeling? •Help me understand, when you have this feeling, what thoughts go through your mind? •Just before you started to have this feeling, what went through your mind, or what were your thoughts? Let’s look at an example of how you could use these questions. Jasmine just found out that her grandfather, who lives out of town, was not feeling well. She has been feeling overwhelming guilt that she had not visited him in a few months. Therapist:When you found out that your grandfather was not feeling well, what were your thoughts? Jasmine:I just felt so guilty. Therapist:Any other thoughts?

The therapist starts by using one of the “Just Ask” questions. When Jasmine was unable to identify a hot thought but kept repeating her feelings, the therapist decided to try and identify the thoughts that went with Jasmine’s feelings. Jasmine:No, just this really strong, overwhelming feeling of guilt. Therapist:Can you go back in your mind to when your mother told you that your grandfather was not well? Jasmine:Sure, I can remember it really clearly. Therapist:Can you focus on your feeling of guilt? Really let yourself feel the guilty feeling. (pausing) I am wondering what thoughts go with this guilty feeling. Jasmine:I just think that a good granddaughter would visit more regularly; now he is sick and old. Video 7.1: Identify Thoughts LIST WORRIES Often when clients are in emotional distress, they worry. Worry is a big component of anxiety, but clients who feel depressed, guilty, ashamed, and angry also often worry. Worry is about expecting bad things to happen. When my client is anxious or worried, I start by making a list of all the “bad things” he is worried will happen. The more concrete the list, the more useful it is. Remember, I am looking for what my client is expecting to happen, not what he is expecting to feel. For example, “I am worried I will be anxious when giving a presentation,” or “I am worried that my presentation will not go well” are less concrete worries than “I am worried I will forget my talk.” Below are some good questions to explore what specifically your client is worried or anxious will happen: •What are you anxious or worried is going to happen? •Is there anything you are specifically worried about happening? •What is the worst that could happen? Or what is your worst-case scenario? •What do you imagine happening? Suzanne’s therapist realized that she did not fully understand what Suzanne was worried would happen at the barbecue. The therapist said, “I can tell that you are pretty anxious about the barbecue. I thought it would be helpful if we could make a list of what you are worried will happen, including your worst-case scenario.” Together they made the following list: When I get there, everyone will be talking to each other, and no one will say hi to me. If I approach one of the new teachers, she will turn her back on me. I will stand there alone, with no one to talk to. If I go up to one of the other teachers and say hi, I will have nothing to say. Clear image of standing next to the barbecue, looking very awkward, holding a glass in my hand. I see myself standing there all alone as everyone else is talking together. Making a specific list of worries can be a very helpful tool to manage anxiety. Often, when clients see their worries written out, they realize that some are unrealistic. I want you to try a quick exercise. Think of an upcoming event that you are somewhat anxious or worried about. Now, write down every bad thing you are worried might happen, and look at the list. Try to make your worry list as specific and concrete as possible. Do your worries seem more manage- able? Maybe some of your worries are reasonable, in which case you can start to problem solve. Making a list takes anxiety from a big ball of bad feelings to specific worries you can start to address. It is one more way to hit the pause button on your automatic negative path.  Exercise 7.2: Isabella Lists Her Worries Practice helping your clients list their worries. Agenda Item #3: Your Clients’ Images Some of the most exciting work in CBT involves working with clients’ images (Hackmann, Bennett- Levy, & Holmes, 2011). Imagery can be a very useful tool to help clients identify their hot thoughts. USE IMAGERY TO RECREATE THE SITUATION Sometimes when you ask your client, “What were you thinking?” he will respond with, “I don’t know.” I usually follow up with one of the “Just Ask” questions. I might say, “Was anything going through your mind?” Often that is enough to prompt my client to start talking about his thoughts, but sometimes my client still says, “I don’t know,” or tells me a thought that is not a hot thought. In that case, one way to help your client identify his thoughts is to ask him to take a moment and imagine himself back in the situation. When a client imagines being back in the situation, some of the feelings he had at the time come back and he has better access to his thoughts. When you recreate a situation using imagery, you can use all of the five senses; however, asking clients to imagine seeing the situation and hearing anything that was said or any other sounds in the environment is often the most effective way to recreate the situation (Richardson, 1999). Here is an example of how recreating the situation in imagery helped Charles identify his thoughts. Charles is newly married and has a two-month-old baby. He has had trouble with alcohol in the past and is trying to drink moderately. He comes to therapy saying he “blew it.” He tells his therapist that a few nights ago he went out with his buddies to a bar for a drink. When he got home he was very depressed and had three glasses of scotch.

Charles: I was so depressed when I got home, I just thought if I had a drink I would feel better. There is no one right way to respond. Before she addressed the drinking, Charles’s therapist wanted to understand what had happened at the bar that he became so depressed. Therapist:When you were out with your buddies, do you remember what you were feeling? Charles:Just normal, sort of down. Therapist:And your thoughts? Charles:Nothing, just hanging out with the guys. CBT theory tells us that if a client becomes distressed, there was a thought that fueled the distress. Charles’s therapist wanted to discover what Charles was thinking that led to his feeling so depressed. Therapist:I am wondering if we could go back to the situation in the bar and try and figure out what was going on with you, in particular your thoughts and feelings. Before you started feeling down, can you remember any particular incident? Charles:My buddies were all talking about the baseball game, and I hadn’t gone with them as I had to stay home with my kid that night. They were drinking and talking about all these plans that I knew I couldn’t do, ’cause I now spend weekends with my wife and son. Therapist:Can you go back to the night in your mind? Take a moment to see the bar, look around. (pauses) See your buddies’ faces. Can you hear them talking about the game they went to? Now hear them talking about the other plans. Take a moment to really go back to the bar in your mind. See if you can remember what is going through your mind as your buddies were talking. The therapist uses both visual and auditory imagery. Charles: I guess I started thinking what a great time they were having, and that now all I do is change diapers and work. Feels like my life is at a dead end. My wife never wants sex anymore; she just complains about how tired she is. Once Charles can identify his thoughts, his depression and drinking make a lot more sense. EXPLORE IMAGES Strong negative feelings are often accompanied by intense affect-provoking images. For example, clients who are scared of spiders tend to have images of huge horrible spiders (Pratt, Cooper, & Hackmann, 2004), and clients who are socially anxious tend to have negative images of themselves in social situations. A socially anxious client may have an image of himself stuttering, sweating, or behav- ing in an extremely awkward manner (Hirsch, Clark, Mathews, & Williams, 2003). Images can also be about the past. It has long been known that clients with post-traumatic stress disorder (PTSD) fre- quently have intrusive images in the form of flashbacks of the traumatic event. What researchers and clinicians are discovering is that clients with a variety of problems can have intrusive images that contribute to their distress. For example, often clients who are depressed have intrusive images of nega- tive events that occurred in the past (Wheatley & Hackmann, 2011). Some clients can easily identify their images; however, many clients become aware of their images only when specifically asked whether images accompany their emotional reaction (Brewin, Christodoulides, & Hutchinson, 1996). In my article “Incorporating Imagery into Thought Records” (Josefowitz, 2017), I describe different types of questions that can help clients identify their images. You can find a Questions to Identify Your Client’s Images handout at http://www.newharbinger.com/38501. Start with a general question. Do you have any images or memories connected with this situation? When you think of this situation, does it bring up any images or memories? Explore worries. Many clients who are anxious have very clear images of their feared event occurring. If your client has a worst-case scenario, be sure to ask whether he actually sees the worst case happen- ing in his mind. Ask about images that accompany your client’s feelings. Do you have any images or memories that accompany your feelings? When you have this feeling, do you ever see pictures or images in your mind of yourself or other people? Ask about images that accompany your client’s verbal thoughts. Clients often have thoughts about themselves (I don’t fit in); thoughts about others (my father is always critical of me); and thoughts about the future (my boss will refuse to pay me overtime). You can ask, “When you have this thought, do you see or imagine this happening? Do you get a picture in your mind of yourself or the other person? What do you see yourself or the other person doing or saying?” Some clients’ images are very detailed and elaborate. Many clients tell themselves long, complex stories; others have very brief, fleeting images. Try to notice your own images. Suzanne had a very clear image of herself standing in the principal’s backyard, looking very awkward. She is holding a drink in her hand and is slightly sweaty. She is all alone and everyone else is happily talking together. Her therapist asked if there were any sounds in her image or if she heard any- thing. Suzanne said she could hear the other teachers talking and laughing, and she was outside the group with nothing to say. Images hold encapsulated meanings. Once you have identified your client’s images, you can ask what these images mean about himself, other people, or the future. Often images hold the same meaning as—and reinforce—the hot thought (Josefowitz, 2017). In Suzanne’s case, her images rein- forced her hot thoughts that no one would want to talk to her and that she would not fit in.  Exercise 7.3: Aabir Explores His Images Practice helping your clients identify their images. Video 7.2: Use Imagery to Explore Thoughts Agenda Item #4: Additional Strategies to Identify Thoughts Clients’ hopes, questions, and mood shifts can also provide glimpses into their thoughts. WHEN THOUGHTS ARE HOPES OR QUESTIONS Thoughts that are hopes or questions pose unique challenges because they do not clearly explain the meaning of the situation. This means that you need to continue to explore these thoughts in order to identify a hot thought. Let me give you some examples. Karl is very depressed. When his therapist asks about his thoughts, he sighs sadly and says he really hopes one day he will have children. This hope is not a thought that captures what his depression is about. If Karl were truly hopeful, he would not be feeling depressed. When clients are depressed or anxious, they sometimes express as hopes the very things they feel hopeless or worried about. Karl’s therapist follows up and asked, “I hear you hope that you will have children; are you worried that will not happen?” Karl became teary and responded, “Yes I think that for me having children is pretty hope- less, and it is the most important thing to me.” Karl’s thought, It is hopeless that I will have children, starts to explain his sadness. Karen is also depressed. When her therapist asks about her thoughts, she becomes teary and says she keeps thinking, Will my husband leave me? The problem is you can’t look for evidence for a ques- tion—you need a statement to look for evidence. You can turn the question into a statement by either rephrasing it or exploring how your client would answer the question. For example, Karen’s therapist rephrased her question by asking Karen, “Are you thinking, My husband will leave me?” Let’s see how Raoul’s therapist helped him further explore a thought that was in the form of a ques- tion. About a week ago, Raoul’s boss asked him to work on a new project with some of his junior col- leagues. He had been procrastinating over contacting them. Raoul was able to identify his feelings and told his therapist he was embarrassed (8) and anxious (8). His therapist then asked him what he was thinking. Raoul:I keep wondering, Why didn’t I get the promotion? Therapist:When you think, Why didn’t I get the promotion, how do you answer the question in your head? Raoul:I guess I think I just wasn’t competent enough. Therapist:So one answer you give yourself is, I just wasn’t competent enough. Do you give yourself any other answers? Raoul:Well, I also think my colleagues and boss don’t respect me, and don’t respect my work. When Raoul’s therapist starts to explore how he answers the question, he starts to identify thoughts about himself, I wasn’t competent enough, and thoughts about others, My colleagues and boss don’t respect me and don’t respect my work.  Exercise 7.4: Carol Wants to Apply for a Job Practice exploring thoughts that are facts, hopes, or questions. USE SHIFTS IN YOUR CLIENT’S MOOD When clients talk about a difficult situation, they often become emotional. A shift in your client’s mood usually goes with an important thought about self, others, or the future. For example, if a client looks sad, blushes, or becomes agitated, it is an opportunity to “catch” important thoughts. I usually say, “I noticed you looked sad [or I noticed you looked upset]; what were you thinking?” Let’s look at an example that Suzanne brought up in the sixth session. Suzanne came into the session saying she wanted to talk about her relationship with her husband. She started in a very calm manner, saying that last night, she said she was tired and wanted to go to bed early. Her husband became annoyed and angry and told her that she was always tired and never wanted to do anything fun anymore. Suzanne started to become teary as she described her husband’s response. Her therapist wanted to identify what thoughts went with her change in mood. Therapist:You looked teary as you remembered what your husband said. Suzanne:Yes, it was pretty awful to hear him say that I never want to go out anymore. Therapist:I am wondering what was going through your mind just now, as you got teary. Suzanne:(looking very sad and more teary) I thought that if I don’t start being more fun, that he will leave me, and I will be all alone. YOUR TURN! Notice Raoul’s Change in Mood Up to now Raoul has mainly focused on work issues. In session 7 he comes in and tells his therapist that his youngest niece may have a serious illness. He explains in a calm voice, “When I think of the pos- sibility of my niece being sick, I know the whole family will just have to find a way to cope, as hard as it will be.” He then goes on: Raoul: We will know for sure whether my niece has the illness on Monday, when we get the results of the lab tests. (His voice cracks, he takes a deep breath, and looks very upset.) How could his therapist use the shift in Raoul’s mood to help him identify his thoughts about the lab results? Look at the three possible responses below and pick the one that will help Raoul identify his thoughts:

  1. What a hard situation. I hope that you are taking care of yourself.
  2. You just looked so upset, I am wondering what was going through your mind when you thought of getting the lab results?
  3. I can see how upset you are, but I also hear how important it is to you to cope. How are you coping? Response #2 is the most likely to lead Raoul to identify the thoughts that accompany his change in mood. In response #1, the therapist tries to be supportive but does not ask about Raoul’s thoughts and is giving advice that Raoul did not ask for. In response #3, the therapist tries to be empathic and then moves to problem solving without having a good definition of the problem. Agenda Item #5: How Do You Know Which Questions to Use? It can be hard to know which question to use, and there is no right answer. Here is a summary of the questions I use, in the general order in which I use them. You may initially find it helpful to keep this list by your side during therapy. (You can download a Questions to Identify Your Client’s Thoughts handout at http://www.newharbinger.com/38501.) The more you use these questions, the more they will start to feel natural. •What were you thinking? Any other thoughts? •When a client’s mood shifts, ask about thoughts. •What does the situation mean to you? OR What does the situation mean about yourself, others, or your future? •How is this situation a problem for you? •What are some of the thoughts that go with your feelings? •Let’s make a list of your worries. Do you have a worst-case scenario? •Do you have any images? •If the thought is a question: How do you answer this question in your mind? •If the thought is a hope: What are you worried about? Let’s use some of these questions to help Michael, a twenty-eight-year-old client of mine, to identify his thoughts. Michael’s main agenda was addressing his anxiety about his relationship with a new girl- friend. He didn’t understand why he was so anxious. We began with identifying situations where he felt anxious. Michael told me that his girlfriend was rarely verbally affectionate toward him; she almost never said she missed him or that she was happy to see him. He described a text message he just received where she said, “See you tonight for dinner.” As he talked about her behavior, he became almost teary. Below is how I explored his thoughts; however, there are many other possible helpful responses. As you read through the dialogue, consider what you would have said. Therapist:When you received the text, what were your thoughts at the time? Michael:I don’t know, it just doesn’t feel good to get a text like that (eyes well up with tears). I started with using one of the “Just Ask” questions. However, Michael responded with a thought that was not a hot thought, so I wanted to try another approach. Therapist: I can see you’re becoming almost teary. What thoughts are going through your mind? I noticed the shift in his mood and thought it probably signaled an important thought. Michael: I know she had a relationship with another man for two years before me. I keep wondering, Did she treat him the same way? Michael’s first thought is a fact: She had a relationship for two years before me. His second thought is a question: Did she treat him the same way? I chose to explore how he answered the question, as there seemed to be more emotion attached to that thought. Therapist:And how do you answer the question, “Did she treat her past boyfriend in the same way”? Michael:I think she treated him differently, or the relationship wouldn’t have lasted. I wanted to explore what it meant to Michael that he thought his girlfriend had treated her previous boy- friend differently. Therapist:If she did treat her previous boyfriend differently, what would it mean to you? Michael:That she doesn’t care about me as much as her previous boyfriend, maybe that she doesn’t really care about me at all. At this point, Michael started to talk with more emotion about his fears that his girlfriend was not com- mitted to the relationship and that he was not very important to her. Agenda Item #6: Link Thoughts to Feelings, Physical Reactions, and Behavior At this point in therapy, you have identified a specific situation that is problematic for your client, and you’ve explored your client’s reaction using the four-factor model. Identifying the relationships among the four factors provides your client with a structure for understanding what is maintaining his problems, and provides you with a way of organizing your client’s treatment. Here’s where the written worksheet Understand Your Reaction comes in handy: you and your client have a document you can look at when developing a model to understand the factors that are maintaining his problem. I start with asking my client to look over the Understand Your Reaction worksheet and ask if he sees a connection among the four factors. Often a client will spontaneously comment that his reaction makes more sense, or that given his thoughts, it makes sense how he is feeling or behaving. If a client does not see the link between his thoughts and his feelings, physical reactions, and behaviors, I point it out to him. For example, I might say, “When I look at your thoughts, it makes sense to me that you would be [a feeling, for example depressed], or do [a behavior, for example procrastinate]. Does this make sense to you?” If my client agrees with me, I ask him to explain the link among the four factors in his own words. Let’s look at the Understand Your Reaction worksheet that Suzanne completed to see how we can help her understand her difficulties. Understand Your Reaction Situation Feelings (Rate 1–10) Physical Reactions BehaviorsThoughts (Rate 1–10) What? Who? What did I feel? Where? When?How did my body react?What did I do?What did I think? Principal invited me to barbecue with the three other new teachersClenched stomach (4)Has not responded• I don’t want to go. Nervous (7) Worried (8) Embarrassed (6) Tense shoulders (5) • The other new teachers will be there. • I won’t fit in. • I will just stand there looking awkward. • No one will want to talk to me. • I will probably get all sweaty. Therapist:Let’s look at what you wrote down. (Suzanne and her therapist look at the worksheet.) When you look at it, do you notice any connection among the four factors? Suzanne:Sort of…I wasn’t aware that I had all of those thoughts. Suzanne’s therapist wants to positively reinforce Suzanne for identifying her thoughts. Rather than telling her, she wants Suzanne to make the link between her thoughts and how she was feeling and behaving. Therapist:You did a really good job of identifying your thoughts. Do you see a connection between your thoughts and your feelings, physical reactions, and behaviors? Suzanne:I do. It makes sense to me that if all these thoughts were going through my head, I would feel anxious. Therapist:I think you are right, and you said it very well. The thoughts really explain your feelings. Notice how Suzanne’s therapist reinforces Suzanne’s understanding of the relationship between her thoughts and her feelings; she tells Suzanne that she articulated the relationship well, and repeats the connection. At this point Suzanne’s therapist would introduce the idea of examining her thoughts, to see if there is any evidence for her beliefs. In the next chapter, we are going to cover how to look for evidence for your clients’ thoughts. DO I ALWAYS EXPLORE ALL FOUR FACTORS? For most clients I use the Understand Your Reaction worksheet. However, you can start with just focusing on one aspect of a client’s problem. For example, remember my client Elsbeth, in chapter 5, who was angry at her son for not doing his homework and chores? We started with just monitoring situ- ations where she was angry. With other clients, if behavior is not part of the presenting problem, I start with exploring feelings, physical reactions, and thoughts. Once my client understands the feeling– thought connection, we add exploring his behaviors. EVALUATING YOUR CLIENT’S WORKSHEET Below are five criteria I use to evaluate whether I need to spend more time exploring any aspect of a client’s Understand Your Reaction worksheet. If a client did not find completing the worksheet helpful, I check that it was done well; if it was not done well, I keep working with my client. You can download Understand Your Reaction Checklist at http://www.newharbinger.com/38501.
  4. Is the situation a factual description of what occurred or does it include feelings, physical reac- tions, behaviors, or thoughts?
  5. Is the feeling really a feeling or is it a thought or behavior?
  6. Did the client rate his or her feelings and physical reactions?
  7. Is the behavior a factual description or does it include feelings, physical reactions, or thoughts?
  8. Are the thoughts hot thoughts? a. Are the thoughts about self, others, or the future? b. Are the thoughts related to the client’s feelings?  Exercise 7.5: Sophia Completes the Understand Your Reaction Worksheet Practice evaluating the Understand Your Reaction worksheet. Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.  Exercise 7.1: (a) Yonas Asks a Question, and (b) Diana Wants to Go to College Exercise 7.2: Isabella Lists Her Worries Exercise 7.3: Aabir Explores His Images Exercise 7.4: Carol Wants to Apply for a Job Exercise 7.5: Sophia Completes the Understand Your Reaction Worksheet Apply What You Learned to Your Own Life Before you try completing the whole Understand Your Reaction worksheet, it is helpful to practice identifying just your thoughts and feelings. Homework Assignment #1 Identify Your Own Feelings and Thoughts This coming week, choose two situations when you had at least a moderately strong negative reaction. Describe the situation, identify and rate your feelings, then identify your thoughts using Questions to Identify Your Client’s Thoughts. Record your responses on the What Are My Feelings and Thoughts? worksheet, which you can download at http://www.newharbinger.com/38501.

What Are My Feelings and Thoughts? SituationFeelings (Rate 1–10)Thoughts What? Who? Where? When?What did I feel?What did I think? Homework Assignment #2 Complete the Understand Your Reaction Worksheet Once you have practiced the What Are My Feelings and Thoughts? worksheet, you are ready to try completing the entire Understand Your Reaction worksheet. There is a copy below, and you can also download it at http://www.newharbinger.com/38501. Once you have identified your thoughts, ask your- self if they are about self, others, or the future.Feelings (Rate 1–10)What did I feel? SituationWhat? Who? Where? When? How did my body react? What did I do? Physical Reactions Behaviors (Rate 1–10) Understand Your Reaction What did I think? Thoughts

Apply What You Learned to Your Therapy Practice It’s time to try the same exercise that you just did, but this time with a client. Homework Assignment #3 Identify Your Client’s Feelings and Thoughts Choose a client who is easy to work with and follow these steps:

  1. Identify a situation that is problematic.
  2. Introduce the What Are My Feelings and Thoughts? worksheet, which you completed in Homework Assignment #1, and explain that you want to use it to help identify your client’s feelings and thoughts.
  3. Identify and rate your client’s feelings.
  4. Use Questions to Identify Your Client’s Thoughts.
  5. Help your client link his or her thoughts to his or her feelings. Homework Assignment #4 Complete the Understand Your Reaction Worksheet with a Client If the last exercise went well, try the Understand Your Reaction worksheet with a client. The first time you try this you may feel awkward and worry about your client’s reaction. This is a normal response to trying something new. However, try to put your worries aside and focus on the task.

Let’s Review Answer the questions under the agenda items. Agenda Item #1: Identify automatic thoughts. • What is the most straightforward way to identify negative automatic thoughts? Agenda Item #2: Helpful questions. • How can you ask what a situation means to your client? Agenda Item #3: Your clients’ images. • What are two good questions you could use to ask about your client’s images? Agenda Item #4: Additional strategies to identifying thoughts. • If a thought is a question or a hope, how can you explore it further? Agenda Item #5: How do you know which questions to use? • What are some of the questions you could use to help your clients identify their thoughts? Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior. • Why is it helpful to look at the relationship among the four factors? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

Back to top