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8. 寻找证据，创造平衡的想法

第三部分

认知和行为干预

第八章

寻找证据并形成平衡的想法

在第七章中，我们讨论了如何帮助客户识别他们的想法。你有机会注意到自己的想法吗？你问过客户他们的想法和感受吗？你发现了什么？

如果你没有完成作业，回想上周发生的一件令人不安的经历。试着识别你的感受和想法。这个情境对你意味着什么？最坏的情况是什么？你有任何图像吗？

设置议程

在本章中，我们将基于《理解你的反应》工作表，学习如何使用思维记录。你将要求客户检查他们负性想法的证据，并发展一个综合考虑所有证据的平衡想法。整个过程称为认知重构。

议程项目 #1：什么是思维记录？

议程项目 #2：解释寻找证据。

议程项目 #3：寻找支持负性想法的证据。

议程项目 #4：寻找反对负性想法的证据。

议程项目 #5：发展平衡的想法。

执行议程

在第五章中，我们讨论了客户有一个根深蒂固的负性自动路径，他们会迅速陷入一团混乱的感觉、生理反应、行为和想法中。暂停客户自动负性反应的一种方法是使用四因素模型帮助客户理解他们的反应。一旦客户识别了他们的感受、生理反应、行为和想法，他们就准备好主动改变他们的负性路径了。帮助客户改变负性路径的一种方法是让他们退一步，检查他们想法的证据。负性想法就像思维习惯一样；我们假设它们是真的，不会停下来质疑它们是否有道理。然而，习惯是可以改变的。寻找证据启动了一个发展新的、更积极的思维习惯的过程，这些习惯基于现实。

议程项目 #1：什么是思维记录？

思维记录本质上是一个帮助客户寻找其“热想法”证据的结构。最简单的形式是，思维记录是一个工作表，客户在其中识别一个有问题的情境，然后记录她在该情境中的感受和想法。客户随后选择一个想法作为关注点。为了使思维记录有效，客户选择的想法必须是一个“热想法”。一旦客户确定了她想要探索的热想法，她就会寻找支持和反对该想法的证据。在客户检查完证据后，她会发展一个新的更平衡或替代的想法。许多思维记录还包括记录生理反应和行为的空间。《理解你的反应》工作表可以用作思维记录的前五列。思维记录通常还涉及让客户评估他们对新平衡想法的相信程度，并在完成思维记录后重新评估他们的感受；但这并不是必需的。以下是完成思维记录的步骤。斜体部分是常见的步骤，但不是必需的。

  1. 识别一个有问题的情境。
  2. 识别并评估感受。
  3. 识别生理反应。
  4. 识别行为。
  5. 识别想法。
  6. 选择一个热想法（与负面感受和对自我、他人或未来的负面评价相关的想法）。
  7. 寻找支持和反对热想法的证据。
  8. 基于所有证据创建一个平衡或替代的想法。
  9. 评估你对新平衡想法的相信程度。
  10. 在检查完证据后重新评估你的感受。

我使用《检查你的想法的现实性》工作表来帮助客户完成思维记录的其余过程。

检查你的想法的现实性

我想要检查的想法 支持我的想法的证据 反对我想法的证据 结论或综合考虑所有证据的想法

思维记录背后的理论是，客户认为他们的负性想法是真实的。要求客户检查他们的想法的证据可以停止他们的自动反应，并开始一个自我反思的过程。当客户检查他们的想法的证据并创建自己的平衡想法时，他们就会发展出新的思维方式和对世界及自己的更不极端的态度。新的思维方式为行为改变打开了可能性。有明确的证据表明，这一认知重构过程与缓解抑郁和焦虑有关（Beck & Dozois, 2011）。

书面思维记录并不是必需的。寻找支持一个想法的证据可以在治疗对话中进行。然而，我鼓励你使用《理解你的反应》和《检查你的想法的现实性》工作表作为书面工具。书面思维记录提供了结构，使识别想法和寻找证据的过程非常具体。一些治疗师喜欢使用七列的思维记录，其中有空间识别四个因素、寻找证据和发展平衡想法。Dennis Greenberger 和 Christine Padesky 在他们的书《心态胜过心情》（2016）中使用了这种类型的思维记录。然而，我个人更喜欢将思维记录分为两个阶段，首先使用《理解你的反应》工作表，然后使用《检查你的想法的现实性》工作表。你可以在 http://www.newharbinger.com/38501 下载这两个工作表。

虽然寻找证据是一个强大的干预措施，但一次寻找证据并不会改变长期的负性想法。客户需要在一段时间内完成许多思维记录，才能改变他们的负性想法。然而，尽管客户的想法在不同情境中有所不同，但大多数客户都有反复出现的负性思维模式。如果你在一个情境中识别了客户的想法，这些想法很可能在其他情境中再次出现。这意味着你为一个情境完成的思维记录通常也适用于其他情境。

选择一个热想法

如果客户有一个与她的情绪困扰密切相关的中心负性热想法，那就是你要关注的想法。然而，客户可能有多个热想法，例如，“我是一个不合格的母亲”和“我的伴侣不爱我”。在这种情况下，客户需要选择要处理哪个想法，因为每次只能检查一个想法的证据。如果客户有多个热想法，我会问：“你觉得哪个想法是最核心的，或者对我们来说最重要的是哪个？”另一个我发现有帮助的问题是：“你觉得哪个想法与你最强的负面情绪最密切相关？”客户通常知道自己需要关注哪个想法。我们的大多数负性想法都是反复出现的。如果客户选择检查“我是一个不合格的母亲”，她还有机会检查“我的伴侣不爱我”。

什么是苏格拉底式提问？

所有认知行为疗法书籍都强调苏格拉底式提问的重要性。这个词源自古希腊哲学家苏格拉底。苏格拉底式提问的核心思想是，技巧性的提问可以帮助客户检查其想法背后的假设，考虑他们忽略的情境方面，或从不同的角度理解他们的处境。你的角色是提出有助于客户以新的视角理解他们问题的问题。

基本理念是，提出帮助客户得出自己结论的问题比直接告诉客户应该怎样想更有效。如果我可以在我所有读者的头上贴一张便签，上面会写着：

你自己得出的结论比别人告诉你的结论更有说服力。

议程项目 #1：什么是思维记录？

思维记录本质上是一个帮助客户寻找其“热想法”证据的结构。最简单的形式是，思维记录是一个工作表，客户在其中识别一个有问题的情境，然后记录她在该情境中的感受和想法。客户随后选择一个想法作为关注点。为了使思维记录有效，客户选择的想法必须是一个“热想法”。一旦客户确定了她想要探索的热想法，她就会寻找支持和反对该想法的证据。在客户检查完证据后，她会发展一个新的更平衡或替代的想法。许多思维记录还包括记录生理反应和行为的空间。《理解你的反应》工作表可以用作思维记录的前五列。思维记录通常还涉及让客户评估他们对新平衡想法的相信程度，并在完成思维记录后重新评估他们的感受；但这并不是必需的。以下是完成思维记录的步骤。斜体部分是常见的步骤，但不是必需的。

  1. 识别一个有问题的情境。
  2. 识别并评估感受。
  3. 识别生理反应。
  4. 识别行为。
  5. 识别想法。
  6. 选择一个热想法（与负面感受和对自我、他人或未来的负面评价相关的想法）。
  7. 寻找支持和反对热想法的证据。
  8. 基于所有证据创建一个平衡或替代的想法。
  9. 评估你对新平衡想法的相信程度。
  10. 在检查完证据后重新评估你的感受。

我使用《检查你的想法的现实性》工作表来帮助客户完成思维记录的其余过程。

检查你的想法的现实性

我想要检查的想法 支持我的想法的证据 反对我想法的证据 结论或综合考虑所有证据的想法

思维记录背后的理论是，客户认为他们的负性想法是真实的。要求客户检查他们的想法的证据可以停止他们的自动反应，并开始一个自我反思的过程。当客户检查他们的想法的证据并创建自己的平衡想法时，他们就会发展出新的思维方式和对世界及自己的更不极端的态度。新的思维方式为行为改变打开了可能性。有明确的证据表明，这一认知重构过程与缓解抑郁和焦虑有关（Beck & Dozois, 2011）。

书面思维记录并不是必需的。寻找支持一个想法的证据可以在治疗对话中进行。然而，我鼓励你使用《理解你的反应》和《检查你的想法的现实性》工作表作为书面工具。书面思维记录提供了结构，使识别想法和寻找证据的过程非常具体。一些治疗师喜欢使用七列的思维记录，其中有空间识别四个因素、寻找证据和发展平衡想法。Dennis Greenberger 和 Christine Padesky 在他们的书《心态胜过心情》（2016）中使用了这种类型的思维记录。然而，我个人更喜欢将思维记录分为两个阶段，首先使用《理解你的反应》工作表，然后使用《检查你的想法的现实性》工作表。你可以在 http://www.newharbinger.com/38501 下载这两个工作表。

虽然寻找证据是一个强大的干预措施，但一次寻找证据并不会改变长期的负性想法。客户需要在一段时间内完成许多思维记录，才能改变他们的负性想法。然而，尽管客户的想法在不同情境中有所不同，但大多数客户都有反复出现的负性思维模式。如果你在一个情境中识别了客户的想法，这些想法很可能在其他情境中再次出现。这意味着你为一个情境完成的思维记录通常也适用于其他情境。

选择一个热想法

如果客户有一个与她的情绪困扰密切相关的中心负性热想法，那就是你要关注的想法。然而，客户可能有多个热想法，例如，“我是一个不合格的母亲”和“我的伴侣不爱我”。在这种情况下，客户需要选择要处理哪个想法，因为每次只能检查一个想法的证据。如果客户有多个热想法，我会问：“你觉得哪个想法是最核心的，或者对我们来说最重要的是哪个？”另一个我发现有帮助的问题是：“你觉得哪个想法与你最强的负面情绪最密切相关？”客户通常知道自己需要关注哪个想法。我们的大多数负性想法都是反复出现的。如果客户选择检查“我是一个不合格的母亲”，她还有机会检查“我的伴侣不爱我”。

什么是苏格拉底式提问？

所有认知行为疗法书籍都强调苏格拉底式提问的重要性。这个词源自古希腊哲学家苏格拉底。苏格拉底式提问的核心思想是，技巧性的提问可以帮助客户检查其想法背后的假设，考虑他们忽略的情境方面，或从不同的角度理解他们的处境。你的角色是提出有助于客户以新的视角理解他们问题的问题。

基本理念是，提出帮助客户得出自己结论的问题比直接告诉客户应该怎样想更有效。如果我可以在我所有读者的头上贴一张便签，上面会写着：

你自己得出的结论比别人告诉你的结论更有说服力。

苏珊娜检查证据

让我们看看如何帮助苏珊娜解决她对校长烧烤邀请的焦虑。她确定的热想法是“没有人会想和我说话”。苏珊娜的治疗师解释了检查证据的过程，苏珊娜愿意尝试。

治疗师: 我们先来看看支持你这个想法的证据，“没有人会想和我说话”。你为什么觉得这可能是真的？

苏珊娜: 嗯，我知道当我参加烧烤时会感到焦虑。

苏珊娜的想法“当我参加烧烤时会感到焦虑”并不是一个事实，而是一个关于她感受的预测。苏珊娜的治疗师希望探讨是否有任何事实支持她的热想法。

治疗师: 我明白你会感到焦虑，但我想知道是否有任何事实支持你认为“没有人会想和你说活”的观点。

苏珊娜: 你是说？

治疗师: 如果我要证明“没有人会想和你说活”，我必须用事实来支持我的观点。比如，在法庭上，法官只会看事实。你明白吗？

治疗师希望确保苏珊娜理解事实的概念。有时使用法庭的类比会有帮助。

苏珊娜: 那我几乎不认识其他老师，这算不算？

治疗师: 当然，这是一个事实。我想知道……这与“没有人想和你说活”有什么关系？

苏珊娜: 嗯，他们都没有主动和我说话。我通常在课间休息时一个人站着，午餐也是一个人吃。

治疗师: 好的，让我们把你说的写下来，以免忘记。你怎么用自己的话表达？（苏珊娜或她的治疗师写。）还有其他什么证据让你认为“没有人会想和你说活”？

请注意，苏珊娜的治疗师正在收集数据；她并没有反驳或解决问题。

苏珊娜: 我觉得主要是午餐和课间休息时。也许早上到校时，也没有人和我打招呼或微笑。

利用过去理解现在

询问客户是否有任何童年或过去的经历支持或与她的负性想法相关，是有帮助的。将她的历史与当前的思维联系起来，可以帮助客户开始意识到过去的真实情况并不一定适用于她的现在生活。

花点时间思考一下你可以如何询问苏珊娜关于过去事件与她的热想法之间的关系。

治疗师: 苏珊娜，你过去有没有什么事情让你觉得“没有人会想和我做朋友”？

苏珊娜: 其实，我在高中的最后一年，有一群非常糟糕的女孩让我过得很惨。她们想在我父母周末不在家时用我家举办饮酒派对，我拒绝了。她们散播关于我的谣言，我几乎失去了所有朋友。那段时间我非常孤独，感觉没有人想和我做朋友。

当客户披露痛苦的回忆时，你需要决定是专注于这段记忆还是继续进行思维记录。一般来说，如果这是客户第一次披露创伤记忆，我会问客户是否希望专注于这段记忆。苏珊娜披露了一段高中的痛苦回忆，虽然令她不安，但并不算是创伤。她的治疗师认为继续进行思维记录比探讨高中记忆更重要。

治疗师: 发生这种事情一定非常令人不安。是不是从那时起你开始觉得“没有人想和我做朋友”？

苏珊娜: 是的，那段时间非常糟糕。从那时起，我变得更加自卑，开始担心别人喜不喜欢我。在此之前，我只是和一群朋友一起玩。

治疗师: 听起来这件事确实改变了你的看法。在另一节治疗中，我们可能需要详细谈谈高中发生的事情。现在，我们能不能把它写在“支持证据”一栏？

让我们看看苏珊娜是如何填写《检查你的想法的现实性》工作表中的“支持我的想法的证据”一栏的。

检查你的想法的现实性

我想要检查的想法 支持我的想法的证据 反对我想法的证据
没有人会想和我做朋友 • 没有人主动和我说话
• 我在课间休息和午餐时都是一个人
• 上学时其他老师早上不会和我打招呼
• 在高中时，有些女孩散播谣言，我几乎失去了所有朋友

议程项目 #4：寻找反对负性想法的证据

客户倾向于关注确认他们负性想法的信息。你的任务是帮助客户关注她通常忽略的信息，这些信息挑战她的负性想法。你可以想象客户生活在一个充满信息的房间里，但只有支持她负性想法的信息是亮着的；房间的其他部分则处于黑暗中。你的任务是通过提问使整个房间都亮起来。一旦整个房间都亮了，客户看到了所有的证据，她就可以决定她之前的信念是否仍然合理。

图8.1展示了治疗师如何用照亮房间的图画帮助医生客户保拉理解她只关注确认她热想法的信息。在一次治疗中，保拉非常沮丧，告诉治疗师她觉得自己不是一个好医生。她支持这一信念的证据是上周她误诊了一位病人，另一位病人因等了半小时而非常生气。保拉和她的治疗师一起查看了反对她信念的证据。保拉指出，她已经成功行医20年，几乎所有病人都很满意，她很少让病人等待；她还举了很多多年来做出复杂诊断的例子。

治疗师画了图8.2来帮助保拉理解她只看到确认她是个坏医生的信息，而所有表明她是好医生的信息都被忽略了或留在黑暗中。治疗师告诉保拉，他们需要照亮所有信息。

图8.1. 保拉的治疗师照亮了被忽略的信息

寻找反对负性想法的证据的三种类型问题

  1. 是否有反对我的负性想法的证据？
  2. 我的负性预测有多大的概率？
  3. 是否有其他视角？

反对客户负性想法的证据

我通常直接问客户是否有任何经历表明她的热想法并不真实，或者并非一直如此。当苏珊娜的治疗师问：“你有没有任何经历表明人们可能愿意成为你的朋友？”苏珊娜轻声回答：“我在以前的学校有一些朋友。”

证据需要具体且详细。检查支持和反对负性自动想法的证据类似于在天平上称重。一边是支持负性想法的证据，另一边是反对负性想法的证据。支持负性想法的证据通常很重，充满了细节。而反对负性想法的证据往往比较抽象，缺乏细节，相比之下显得较轻。客户提供的反对负性想法的证据越具体、越详细，她的情感投入就越多，反对负性想法的证据就越有分量，相比支持负性想法的证据也会显得更重。

苏珊娜反对她热想法的证据是“我有一些朋友。”这并不是很强或情感上有说服力的证据。为了使证据更具说服力，她的治疗师首先要求具体的例子，然后询问这些例子的详细情况。以下是治疗师问的一些问题：

  • 你能给我举一些朋友的例子吗？
  • 当你说“有一些朋友”时，能告诉我更多关于他们的情况吗？
  • 你在学校和校外与朋友做了哪些事情？
  • 你是怎么知道他们愿意成为你的朋友的？

治疗师发现，苏珊娜在以前的学校与许多老师关系友好，但她有两个好朋友，丽塔和法伊扎。她们通常一起吃午饭，一起参与学校的戏剧制作。她们经常在周末见面，有时还会带着孩子和配偶聚会。苏珊娜觉得她们很有趣、善良、温暖，和她们在一起很开心。自从搬到新学校后，她与她们见面的机会少了。她们经常打电话问她周末是否想一起做些什么，但苏珊娜太累了。前几天，法伊扎还特意带了一个蛋糕来看望苏珊娜，以安慰她。

将证据变得更具体和详细后，效果如何？是否更具情感上的说服力？当治疗师探讨苏珊娜与丽塔和法伊扎友谊的细节时，苏珊娜的心情有所好转。当她的心情好转时，她也更容易记起其他挑战她负性自动想法的情境。图8.3捕捉了使证据更重的理念：当苏珊娜反对她热想法“没有人会想和我做朋友”的证据变得更具体和详细时，这些证据变得更有说服力。

图8.3. 使证据更重

支持我的想法的证据 反对我想法的证据
没有人主动和我说话 我有一些朋友
我在课间休息和午餐时都是一个人 丽塔和法伊扎是我的好朋友
上学时其他老师早上不会和我打招呼 我们通常一起吃午饭，一起参与学校的戏剧制作
高中时的谣言，失去的朋友 我们经常在周末见面，有时还会带着孩子和配偶聚会
法伊扎带蛋糕来看望我，安慰我

反对的证据

支持的证据 反对的证据
没有人主动和我说话 和丽塔和法伊扎是好朋友
我在课间休息和午餐时都是一个人 经常一起吃午饭
上学时其他老师早上不会和我打招呼 一起参与学校的戏剧制作
高中时的谣言，失去的朋友 经常在周末一起聚会
我有一些朋友

图8.3. 权衡苏珊娜的证据

练习8.1：苏珊娜对丈夫感到不满

练习使证据具体和详细。

附加问题以挑战客户的热想法

客户可能需要额外的帮助来思考反对他们热想法的证据。以下问题是受到多位杰出的认知行为疗法治疗师的启发，包括Judy Beck（2011年）、Dennis Greenberger和Christine Padesky（2016年），以及Jackie Persons及其同事（2001年）。你可以在 http://www.newharbinger.com/38501 下载《识别反对负性想法的证据问题》手册。

  • 你会对有这种想法的人说什么？
  • 如果你的朋友或关心你的人知道你有这种想法，他们会说什么？
  • 如果你心情更好，你会怎么想？
  • 五年后回顾，你可能会怎么想？
  • 有任何信息与你的解读相矛盾吗？即使是小的信息？
  • 你忽略了任何积极的信息吗？

让我们看看苏珊娜的治疗师是如何使用其中一些问题的。

治疗师: 听起来丽塔和法伊扎是很好的朋友。如果你告诉她们你在想“没有人会想和我做朋友”，你觉得她们会说什么？

苏珊娜: 她们会觉得这很荒谬。当然会有人想和我做朋友。

治疗师希望扩展这一证据。

治疗师: 如果她们真的想说服你，她们可能会告诉你哪些证据呢？

苏珊娜: 嗯，她们可能会提醒我以前学校的朋友们；她们也会提醒我她们喜欢我。

治疗师: 所以她们会提醒你以前学校的朋友们，以及她们喜欢你。那么，丽塔和法伊扎喜欢你这一事实，是如何作为“没有人会想和我做朋友”的反对证据的？

治疗师先总结了客户的陈述，然后将证据与热想法联系起来。

苏珊娜（犹豫地）: 嗯，我想，如果她们喜欢我，其他人也可能喜欢我？

治疗师（微笑）: 你认为这可能是真的吗？

苏珊娜（微笑）: 是的，我想是这样的。

鉴于苏珊娜的情绪有所好转，她更有可能记住其他积极的信息。

治疗师: 我想知道你是否忽略了任何积极的信息。

苏珊娜（微笑）: 仔细想想，其实有不少。大学时我有很多好朋友，我仍然和他们见面，至少在我不抑郁之前是这样。我还有一些来自社区的朋友，周末会在公园见到他们。

你如何扩展苏珊娜刚刚讨论的证据？记住，先要求一个例子，然后再要求详细信息。

苏珊娜的证据已经开始看起来非常不同！

我想要检查的想法：没有人会想和我做朋友

支持我的想法的证据 反对我的想法的证据
没有人主动和我说话 在以前的学校有一些朋友
我在课间休息和午餐时都是一个人 丽塔和法伊扎是好朋友；一起吃午饭；一起参与学校的戏剧制作；周末一起聚会；有时会一起出去；她们还打电话问我是否想做些什么；法伊扎带来了蛋糕
上学时其他老师早上不会和我打招呼 大学时的朋友，我仍然和他们见面
高中时的谣言，失去的朋友 社区里的朋友

视频8.1：寻找证据

我的预测有多大的概率？

客户的思维常常涉及未来，包括负性的预测。例如：没有人会喜欢我，我会考试不及格，我不会得到这份工作，或者没有人会喜欢我的Facebook帖子。当思维涉及未来时，你需要寻找证据来评估负性事件发生的可能性。以下是通常使用的步骤：

  1. 识别客户害怕会发生的事情，并尽可能具体地列出这些事件。
  2. 评估每个害怕的事件发生的概率。
  3. 检查每个害怕的事件发生的概率的证据。
  4. 重新评估每个害怕的事件发生的概率。

我的预测有多大的概率？

我经常使用以下的工作表《我的预测有多大的概率？》，你可以在 http://www.newharbinger.com/38501 下载完整版本。

我的预测有多大的概率？

我害怕会发生的事情 发生的概率 支持概率的证据 反对概率的证据 重新评估发生概率
(0–100%)

这是苏珊娜列出的她在烧烤会上害怕会发生的事情：

  • 当我到达时，每个人都会互相交谈，没有人会和我打招呼。
  • 如果我接近一位新老师，她会背对着我。
  • 我会独自站在那里，没有人可以交谈。
  • 如果我走到其他老师面前，我将无话可说。
  • 清晰地想象自己站在烧烤架旁边，看起来非常尴尬，手里拿着一杯饮料，而其他人都在互相交谈，只有我一个人。

评估每个事件发生的概率。苏珊娜的治疗师让她从0到100%评估每个事件发生的可能性。苏珊娜认为前三个事件以及她的想象都非常不可能，评分为20%。治疗师问她是什么让这些事件不太可能发生。苏珊娜笑着说，这是一个小团体，校长会确保每个人都能找到交谈的对象。她认为“无话可说”是很可能的，评分为80%。

检查证据。苏珊娜和她的治疗师一起检查了“如果我走到其他老师面前，我将无话可说”的证据。苏珊娜解释说，当她感到焦虑时，有时很难找到话题。这种情况曾经发生在她丈夫的节日聚会上。

当苏珊娜和她的治疗师检查反对她预测的证据时，她能够想到很多例子，即使在社交活动中很难找到话题，她还是找到了可以说的话。即使在她丈夫的节日聚会上，她也能和丈夫的同事找到话题。

重新评估概率。在检查了证据之后，苏珊娜将无话可说的概率评估为约50%。前后概率的评估可以让客户看到概率有所下降，即使概率不是0。

你可以在 http://www.newharbinger.com/38501 查看苏珊娜和她的治疗师是如何完成《我的预测有多大的概率？》工作表的。

真实和虚假警报

Friedberg、Friedberg和Friedberg（2001）有一个很好的练习，帮助客户检查他们的负性预测是否实际发生。治疗师让客户列出下周的所有担忧，下一周再检查哪些担忧实际发生了。大多数情况下，大多数担忧都是“虚假警报”。

不确定性的容忍

除非客户的负性预测完全离谱，否则没有人能保证这些预测不会发生。客户需要学会容忍不确定性（Dugas & Robichaud, 2007）。这可能很难，但第一步是诚实地与客户讨论接受生活的不确定性，尽管不是不可能，但所担心的事件发生的概率很小。

视频8.2：我的预测有多大的概率？

是否有其他视角？

有时客户的负性想法是基于对事件的过于消极的解读；你需要帮助客户找到一个更温和的解释。让我们看一个例子。罗尔因为一位同事在走廊里走过他身边没有打招呼而感到不安。罗尔认为这意味着他的同事在回避他。另一种可能的解释是，他的同事可能很匆忙或心事重重。

有时简单地问客户是否能想到不同的视角就足以让她开始以不同的方式思考。然而，有时你需要更积极。以下两种方法可以帮助客户达到更温和的解释：（1）仔细审视情况的事实；（2）探讨客户是否在为她无法控制的事情责怪自己。

仔细审视情况的事实

客户倾向于关注强化他们想法的狭窄信息；你的任务是帮助客户拓宽视角，审视情况的所有事实，看看是否有更平衡的解释。

你还记得在上一章中，罗尔因为被分配与初级同事合作撰写报告而极度不安吗？他认为这意味着老板不尊重他。以下是你可以用的问题来帮助客户检查她对情况的解读。你可以在 http://www.newharbinger.com/38501 下载《收集更多关于情况的信息问题》手册。

  • 这种情况是如何发生的？
  • 你将与谁一起工作/互动？
  • 是否有任何信息与你的解读相矛盾？即使是小的信息？
  • 你是否忽略了任何积极的信息？
  • 你是否有过类似的行为？你的动机是什么？

让我们看看当罗尔的治疗师使用这些问题来探讨罗尔对情况的解读时会发生什么。

收集更多关于情况的信息的问题

问题 罗尔的回答
这种情况是如何发生的？ 我的老板走近我，说他希望我参与这个报告，因为他认为我有必要的专业知识，并且之前做过类似的工作。
你将与谁一起工作/互动？ 两位在过去两年内入职的初级同事。
是否有任何信息与你的解读相矛盾？即使是小的信息？ 往往资深人员会被要求与初级人员一起合作撰写报告。在公司里这是很常见的。
你是否忽略了任何积极的信息？ 一位初级同事告诉我，她很高兴我能加入团队，她听说过我的好口碑。
你是否有过类似的行为？你的动机是什么？ 以前，我曾安排一位资深人员参与一个项目，以确保项目中有具备必要专业知识的人。

罗尔的治疗师问他，这些额外的信息是否对他认为被分配到这个项目意味着老板不尊重他的想法有任何影响。罗尔回答说，这可能意味着他们希望在这个项目中有一位资深人员。我在寻找客户信念中的裂缝。就像水渗入石头一样，只要能找到一个小裂缝，它就会逐渐扩大。

轮到你了！

帮助苏珊娜仔细审视事实

苏珊娜非常沮丧，因为没有老师在课间休息时和她说话。这是她认为没有人愿意成为她朋友的关键证据之一。她的治疗师认为值得尝试看看是否有更温和的解释。

治疗师: 你用来支持“没有老师愿意成为你朋友”这一信念的一个重要证据是，没有人会在课间休息时和你说话。

请看下面三种可能的回应，选择一个能帮助苏珊娜开始收集有关情况的事实的回应。

  1. 我觉得奇怪，他们为什么不和你说话；他们听起来像是一群可怕的人。
  2. 你能不能加入某个老师的小组？
  3. 你能描述一下课间休息时发生了什么，其他老师做了什么，你自己又做了什么？

最佳回应：第3个问题是最好的问题，有助于收集关于课间休息时发生的情况的信息。根据回答，治疗师可以采取不同的跟进方式。第1个回应支持了苏珊娜对情况的解读。第2个回应在问题明确之前就开始了解决问题的过程。

治疗师: 你能描述一下课间休息时发生了什么，其他老师做了什么？

苏珊娜: 我们每个人都有负责的区域。实际上，当我仔细想想，只有负责攀爬架的两位老师站在一起。其他人都单独站在操场上。有些老师可能会互相靠近说几句话。我只是站在操场后面的秋千旁。

请看下面三种可能的回应，选择一个能帮助苏珊娜开始获得不同视角的回应。

  1. 我听说每个人都有指定的区域，而且大多数老师都是单独站着的；我说得对吗？
  2. 孩子们的纪律问题严重吗？你发现哪些方法有助于维持秩序？
  3. 我觉得每个人都是单独站着的，这并不意味着他们不想和你说话。

最佳回应：第1个回应是最好的。它是对苏珊娜告诉治疗师的信息的总结，最有可能鼓励她考虑单独站在课间休息时意味着什么的不同视角。第2个回应中，治疗师正在收集关于情况的数据，但这些数据与苏珊娜的信念“没有人愿意成为我的朋友”无关。第3个回应中，治疗师在告诉苏珊娜应该怎样想。

本章知识点阐述

进一步阐述的知识点

  1. 设置议程

    • 定义：在治疗过程中，通过设置议程来引导客户逐步理解并改变他们的负性路径。
    • 方法：
      • 回顾前一章：回顾第七章的内容，确保客户已经学会了识别自己的想法和感受。
      • 引入新概念：介绍认知重构的概念，解释思维记录的作用。
    • 效果：通过设置清晰的议程，帮助客户有条不紊地进行治疗，逐步改变他们的负性思维模式。

  2. 什么是思维记录

    • 定义：思维记录是一种工具，用于记录客户的负性想法及其相关的感受、生理反应和行为。
    • 方法：
      • 填写工作表：指导客户详细填写思维记录工作表，包括情境、感受、生理反应、行为和想法。
      • 评估内容：检查客户填写的内容，确保他们正确地识别和记录了相关信息。
    • 效果：通过使用思维记录，帮助客户更具体地识别和理解自己的负性想法，从而为进一步的干预打下基础。

  3. 解释寻找证据

    • 定义：寻找证据是指帮助客户检查他们的负性想法是否有事实依据。
    • 方法：
      • 具体问题：使用具体的问题，如“你有什么证据支持这个想法？”
      • 逐步引导：通过逐步引导，帮助客户系统地检查他们的想法。
    • 效果：通过寻找证据，帮助客户更客观地评估他们的负性想法，从而减少无根据的负面情绪。

  4. 寻找支持负性想法的证据

    • 定义：帮助客户识别支持他们负性想法的证据。
    • 方法：
      • 具体问题：使用具体的问题，如“你有什么证据支持这个想法？”
      • 记录证据：指导客户记录支持他们负性想法的证据。
    • 效果：通过识别支持负性想法的证据，帮助客户更具体地理解他们的想法，从而为进一步的干预打下基础。

  5. 寻找反对负性想法的证据

    • 定义：帮助客户识别反对他们负性想法的证据。
    • 方法：
      • 具体问题：使用具体的问题，如“你有什么证据反对这个想法？”
      • 记录证据：指导客户记录反对他们负性想法的证据。
    • 效果：通过识别反对负性想法的证据，帮助客户更全面地评估他们的想法，从而减少无根据的负面情绪。

  6. 发展平衡的想法

    • 定义：帮助客户发展一个综合考虑所有证据的平衡想法。
    • 方法：
      • 综合证据：指导客户综合考虑支持和反对负性想法的证据。
      • 形成平衡想法：帮助客户形成一个更平衡、更现实的想法。
    • 效果：通过发展平衡的想法，帮助客户更客观地看待问题，从而减少无根据的负面情绪，提高心理健康水平。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 什么是思维记录？

    • 定义：思维记录是一种结构化的工具，帮助客户识别和评估他们的负性想法，并发展更平衡的想法。
    • 方法：
      • 识别情境：客户识别一个有问题的情境。
      • 记录感受和想法：客户记录他们在该情境中的感受和想法。
      • 选择热想法：客户选择一个与负面感受和对自我、他人或未来的负面评价相关的想法。
      • 寻找证据：客户寻找支持和反对该想法的证据。
      • 发展平衡想法：客户基于所有证据发展一个新的更平衡或替代的想法。
    • 效果：通过使用思维记录，帮助客户更具体地识别和理解他们的负性想法，从而减少无根据的负面情绪，提高心理健康水平。

  2. 选择一个热想法

    • 定义：选择一个与客户情绪困扰密切相关的中心负性热想法。
    • 方法：
      • 识别多个热想法：如果客户有多个热想法，帮助他们选择最核心或最重要的一个。
      • 提问引导：使用具体的问题，如“你觉得哪个想法与你最强的负面情绪最密切相关？”
    • 效果：通过选择一个热想法，帮助客户集中精力处理最关键的问题，从而更有效地进行治疗。

  3. 苏格拉底式提问

    • 定义：苏格拉底式提问是一种技巧性的提问方法，旨在帮助客户检查其想法背后的假设，考虑他们忽略的情境方面，或从不同的角度理解他们的处境。
    • 方法：
      • 提出开放性问题：提出开放式问题，帮助客户自己思考和得出结论。
      • 避免直接告知：避免直接告诉客户应该怎样想，而是引导他们自己思考。
    • 效果：通过苏格拉底式提问，帮助客户更深入地理解自己的问题，从而发展出新的思维方式和更健康的行为模式。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 什么是思维记录？

    • 定义：思维记录是一种结构化的工具，帮助客户识别和评估他们的负性想法，并发展更平衡的想法。
    • 方法：
      • 识别情境：客户识别一个有问题的情境。
      • 记录感受和想法：客户记录他们在该情境中的感受和想法。
      • 选择热想法：客户选择一个与负面感受和对自我、他人或未来的负面评价相关的想法。
      • 寻找证据：客户寻找支持和反对该想法的证据。
      • 发展平衡想法：客户基于所有证据发展一个新的更平衡或替代的想法。
    • 效果：通过使用思维记录，帮助客户更具体地识别和理解他们的负性想法，从而减少无根据的负面情绪，提高心理健康水平。

  2. 选择一个热想法

    • 定义：选择一个与客户情绪困扰密切相关的中心负性热想法。
    • 方法：
      • 识别多个热想法：如果客户有多个热想法，帮助他们选择最核心或最重要的一个。
      • 提问引导：使用具体的问题，如“你觉得哪个想法与你最强的负面情绪最密切相关？”
    • 效果：通过选择一个热想法，帮助客户集中精力处理最关键的问题，从而更有效地进行治疗。

  3. 苏格拉底式提问

    • 定义：苏格拉底式提问是一种技巧性的提问方法，旨在帮助客户检查其想法背后的假设，考虑他们忽略的情境方面，或从不同的角度理解他们的处境。
    • 方法：
      • 提出开放性问题：提出开放式问题，帮助客户自己思考和得出结论。
      • 避免直接告知：避免直接告诉客户应该怎样想，而是引导他们自己思考。
    • 效果：通过苏格拉底式提问，帮助客户更深入地理解自己的问题，从而发展出新的思维方式和更健康的行为模式。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 解释寻找证据

    • 定义：寻找证据是指教会客户检查他们的想法是否真实，而不是将想法当作事实。
    • 方法：
      • 识别热想法：帮助客户识别一个与负面情绪相关的热想法。
      • 解释过程：向客户解释寻找支持和反对热想法的证据的过程。
      • 强调事实：强调在寻找证据时要专注于事实，以便评估想法的准确性。
    • 效果：通过解释寻找证据，帮助客户学会退一步，与自己的想法保持距离，从而更客观地评估自己的想法。

  2. 利用过去理解现在

    • 定义：询问客户是否有任何童年或过去的经历支持或与他们的负性想法相关，以帮助他们理解当前的思维模式。
    • 方法：
      • 提问引导：使用具体的问题，如“你过去有没有什么事情让你觉得‘没有人会想和我做朋友’？”
      • 记录证据：帮助客户记录支持和反对他们想法的证据。
    • 效果：通过利用过去的经历，帮助客户理解当前的思维模式，并认识到过去的真实情况并不一定适用于现在的现实生活。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 寻找反对负性想法的证据

    • 定义：寻找反对负性想法的证据是指帮助客户关注那些通常被忽略的信息，这些信息可以挑战客户的负性想法。
    • 方法：
      • 提问引导：使用特定的问题帮助客户识别和评估反对他们负性想法的证据。
      • 视觉辅助：使用图表或图画帮助客户直观理解他们忽视的信息。
    • 效果：通过寻找反对负性想法的证据，帮助客户更全面地看待问题，从而更客观地评估自己的想法。

  2. 三种类型的问题

    • 是否有反对我的负性想法的证据？
      • 定义：寻找直接反对客户负性想法的具体证据。
      • 方法：引导客户列举具体的例子，如过去的成功经历、他人的正面反馈等。
    • 我的负性预测有多大的概率？
      • 定义：评估客户负性预测的实际可能性。
      • 方法：引导客户分析实际情况，考虑各种可能的结果及其发生的概率。
    • 是否有其他视角？
      • 定义：帮助客户从不同的角度看待问题，考虑其他合理的解释。
      • 方法：引导客户思考其他人可能会如何看待这个问题，或者考虑不同的假设。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 反对客户负性想法的证据

    • 定义：反对客户负性想法的证据是指帮助客户关注那些通常被忽略的信息，这些信息可以挑战客户的负性想法。
    • 方法：
      • 提问引导：使用特定的问题帮助客户识别和评估反对他们负性想法的证据。
      • 具体化和详细化：引导客户提供具体的例子，并详细描述这些例子。
    • 效果：通过寻找反对负性想法的证据，帮助客户更全面地看待问题，从而更客观地评估自己的想法。

  2. 具体化和详细化的重要性

    • 定义：具体化和详细化是指将抽象的证据转化为具体、详细的例子。
    • 方法：
      • 具体例子：引导客户提供具体的例子，如过去的成功经历、他人的正面反馈等。
      • 详细描述：引导客户详细描述这些例子，包括时间、地点、人物、事件等。
    • 效果：具体化和详细化的证据更具有情感上的说服力，能够帮助客户更深刻地认识到自己的负性想法并不完全正确。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 反对的证据

    • 定义：反对的证据是指帮助客户关注那些通常被忽略的信息，这些信息可以挑战客户的负性想法。
    • 方法：
      • 提问引导：使用特定的问题帮助客户识别和评估反对他们负性想法的证据。
      • 具体化和详细化：引导客户提供具体的例子，并详细描述这些例子。
    • 效果：通过寻找反对负性想法的证据，帮助客户更全面地看待问题，从而更客观地评估自己的想法。

  2. 附加问题以挑战客户的热想法

    • 定义：这些问题是帮助客户从不同角度思考，找出反对他们负性想法的证据。
    • 方法：
      • 外部视角：引导客户想象朋友或关心他们的人会怎么说。
      • 未来视角：引导客户从未来的角度看待当前的问题。
      • 积极信息：引导客户注意他们可能忽略的积极信息。
    • 效果：通过这些附加问题，帮助客户更全面地评估他们的想法，减少认知扭曲，增强自信心。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 积极信息的识别

    • 定义：积极信息是指客户可能忽略的正面信息，这些信息可以挑战他们的负性想法。
    • 方法：
      • 提问引导：使用特定的问题帮助客户识别和评估他们忽略的积极信息。
      • 具体化和详细化：引导客户提供具体的例子，并详细描述这些例子。
    • 效果：通过识别积极信息，帮助客户更全面地看待问题，从而更客观地评估自己的想法。

  2. 评估预测的概率

    • 定义：评估预测的概率是指帮助客户评估他们负性预测发生的可能性。
    • 方法：
      • 具体化：识别客户害怕会发生的事情，并尽可能具体地列出这些事件。
      • 评估概率：评估每个害怕的事件发生的概率。
      • 检查证据：检查每个害怕的事件发生的概率的证据。
      • 重新评估：基于新的证据，重新评估每个害怕的事件发生的概率。
    • 效果：通过评估预测的概率，帮助客户更理性地看待未来的可能性，减少过度担忧和焦虑。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 评估预测的概率

    • 定义：评估预测的概率是指帮助客户评估他们负性预测发生的可能性。
    • 方法：
      • 具体化：识别客户害怕会发生的事情，并尽可能具体地列出这些事件。
      • 评估概率：评估每个害怕的事件发生的概率。
      • 检查证据：检查每个害怕的事件发生的概率的证据。
      • 重新评估：基于新的证据，重新评估每个害怕的事件发生的概率。
    • 效果：通过评估预测的概率，帮助客户更理性地看待未来的可能性，减少过度担忧和焦虑。

  2. 检查证据

    • 定义：检查证据是指帮助客户识别支持和反对他们负性预测的具体证据。
    • 方法：
      • 支持证据：引导客户列举支持他们负性预测的具体例子。
      • 反对证据：引导客户列举反对他们负性预测的具体例子。
    • 效果：通过检查证据，帮助客户更全面地评估他们的预测，减少认知扭曲，增强自信心。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 检查反对预测的证据

    • 定义：检查反对预测的证据是指帮助客户识别和评估反对他们负性预测的具体证据。
    • 方法：
      • 具体化：引导客户提供具体的例子，即使这些例子在当时很难找到。
      • 重新评估：基于新的证据，重新评估预测发生的概率。
    • 效果：通过检查反对预测的证据，帮助客户更理性地看待未来的可能性，减少过度担忧和焦虑。

  2. 真实和虚假警报

    • 定义：真实和虚假警报是指帮助客户检查他们的负性预测是否实际发生。
    • 方法：
      • 列出担忧：让客户列出即将发生的一周内的所有担忧。
      • 检查结果：下一周再检查哪些担忧实际发生了。
    • 效果：通过这个练习，帮助客户认识到大多数担忧都是“虚假警报”，从而减少不必要的焦虑。

  3. 不确定性的容忍

    • 定义：不确定性的容忍是指帮助客户学会接受生活的不确定性。
    • 方法：
      • 诚实讨论：诚实地与客户讨论接受生活的不确定性。
      • 评估概率：虽然不能保证负性事件不会发生，但要帮助客户认识到这些事件发生的概率很小。
    • 效果：通过提高对不确定性的容忍度，帮助客户减少过度担忧，增强应对不确定性的能力。

  4. 是否有其他视角

    • 定义：是否有其他视角是指帮助客户找到对事件的更温和的解释。
    • 方法：
      • 仔细审视事实：引导客户仔细审视情况的所有事实，看看是否有更平衡的解释。
      • 探讨责任：探讨客户是否在为她无法控制的事情责怪自己。
    • 效果：通过寻找其他视角，帮助客户更客观地看待问题，减少不必要的负面情绪。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 仔细审视情况的事实

    • 定义：仔细审视情况的事实是指帮助客户识别和评估情况的所有相关事实，以便找到更平衡的解释。
    • 方法：
      • 提问引导：使用特定的问题帮助客户收集更多关于情况的信息。
      • 具体化：引导客户提供具体的例子和详细信息。
    • 效果：通过仔细审视事实，帮助客户更全面地理解情况，减少认知扭曲，增强自信心。

  2. 探讨责任

    • 定义：探讨责任是指帮助客户识别他们是否在为他们无法控制的事情责怪自己。
    • 方法：
      • 自我反思：引导客户思考他们是否有过类似的行为，以及当时的动机是什么。
    • 效果：通过探讨责任，帮助客户更客观地看待问题，减少不必要的自责和负面情绪。

  3. 寻找信念中的裂缝

    • 定义：寻找信念中的裂缝是指帮助客户识别他们负性信念中的薄弱环节，以便逐步改变这些信念。
    • 方法：
      • 提供反例：引导客户提供与他们负性信念相矛盾的具体例子。
      • 逐步质疑：通过逐步提问，帮助客户质疑和修正他们的负性信念。
    • 效果：通过寻找信念中的裂缝，帮助客户逐步改变不合理的信念，建立更健康的思维模式。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

进一步阐述的知识点

  1. 仔细审视事实

    • 定义：仔细审视事实是指帮助客户识别和评估情况的所有相关事实，以便找到更平衡的解释。
    • 方法：
      • 提问引导：使用特定的问题帮助客户收集更多关于情况的信息。
      • 具体化：引导客户提供具体的例子和详细信息。
    • 效果：通过仔细审视事实，帮助客户更全面地理解情况，减少认知扭曲，增强自信心。

  2. 获得不同视角

    • 定义：获得不同视角是指帮助客户找到对情况的更温和的解释，从而减少过度负面的解读。
    • 方法：
      • 总结信息：总结客户提供的信息，帮助他们从不同的角度看待问题。
      • 避免直接指导：避免直接告诉客户应该如何想，而是引导他们自己发现不同的视角。
    • 效果：通过获得不同视角，帮助客户更客观地看待问题，减少不必要的负面情绪。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。### 进一步阐述的知识点

  1. 仔细审视事实

    • 定义：仔细审视事实是指帮助客户识别和评估情况的所有相关事实，以便找到更平衡的解释。
    • 方法：
      • 提问引导：使用特定的问题帮助客户收集更多关于情况的信息。
      • 具体化：引导客户提供具体的例子和详细信息。
    • 效果：通过仔细审视事实，帮助客户更全面地理解情况，减少认知扭曲，增强自信心。

  2. 获得不同视角

    • 定义：获得不同视角是指帮助客户找到对情况的更温和的解释，从而减少过度负面的解读。
    • 方法：
      • 总结信息：总结客户提供的信息，帮助他们从不同的角度看待问题。
      • 避免直接指导：避免直接告诉客户应该如何想，而是引导他们自己发现不同的视角。
    • 效果：通过获得不同视角，帮助客户更客观地看待问题，减少不必要的负面情绪。

实践建议

  • 家庭作业：要求客户在日常生活中注意并记录自己的自动思绪和情绪变化，帮助他们逐步识别和纠正这些不合理的思维模式。
  • 持续支持：在后续的治疗中，继续帮助客户识别和纠正这些认知扭曲，逐步建立更健康的思维模式。

通过上述内容的学习和应用，咨询师可以更加有效地帮助客户认识和管理自己的思维模式和情绪，从而促进心理健康和个人成长。

PART 3 Cognitive and Behavioral Interventions

CHAPTER 8 Look for Evidence and Create Balanced Thoughts In chapter 7 we covered how to help your clients identify their thoughts. Did you have a chance to notice your own thoughts? Did you ask your clients about their thoughts and feelings? What did you discover? If you did not do the homework, think about an upsetting experience that happened last week. Try to identify your feelings and thoughts. What did the situation mean to you? What was your worst-case scenario? Did you have any images? Set the Agenda In this chapter we are going to build on the Understand Your Reaction worksheet and learn how to work with thought records. You will ask your clients to examine the evidence for their negative thoughts and develop a balanced thought that takes into consideration all of the evidence. The whole process is called cognitive restructuring. Agenda Item #1: What are thought records? Agenda Item #2: Explain looking for evidence. Agenda Item #3: Find evidence that supports negative thoughts. Agenda Item #4: Find evidence against negative thoughts. Agenda Item #5: Develop balanced thoughts. Work the Agenda In chapter 5 we talked about how your client has a well-worn automatic negative path that she zooms down, ending up in a big black jumbled ball of feelings, physical reactions, behaviors, and thoughts. One way to hit the pause button on your client’s automatic negative reaction is to use the four-factor model to help your client understand her reaction. Once your client has identified her feelings, physical reactions, behaviors, and thoughts, she is ready to actively change her negative path. One way to help your client change her negative path is to ask her to step back and examine the evidence for her thoughts. Negative thoughts are like thinking habits; we assume they are true and don’t stop to ques- tion whether they make sense. However, habits can be changed. Looking for evidence starts a process of developing new and more positive thought habits that are based on reality. Agenda Item #1: What Are Thought Records? A thought record is essentially a structure for helping your client look for the evidence for her hot thoughts. In its simplest form, a thought record is a worksheet where a client identifies a problematic situation and then records her feelings and thoughts about the situation. The client then choses one thought to focus on. For a thought record to be effective, the thought the client chooses needs to be a hot thought. Once your client has identified the hot thought she wants to explore, she then looks for the evidence for and against her thought. After the client has examined the evidence, she develops a new more balanced or alternative thought. Many thought records also include space to record physical reactions and behavior. The Understand Your Reaction worksheet can be used as the first five columns of a thought record. Thought records also frequently involve having clients rate how much they believe their new balanced thought and rerate their feelings after completing the thought record; however, this is not essential. Below are the steps to complete a thought record. The steps in italics are common but not essential to the process.

  1. Identify a problematic situation.
  2. Identify and rate feelings.
  3. Identify physical reactions.
  4. Identify behaviors.
  5. Identify thoughts.
  6. Choose a hot thought (a thought that is related to a negative feeling and a negative evaluation of self, other, or the future).
  7. Look for evidence for and against the hot thought.
  8. Create a balanced or alternative thought based on all of the evidence.
  9. Rate the extent to which you believe the new balanced thought.
  10. Rate your feelings now that you have examined the evidence. I use the Examine the Reality of Your Thoughts worksheet, which follows, to help clients complete the rest of the thought record process. Examine the Reality of Your Thoughts Thought I want to examine: Evidence for My Thought Evidence Against My Thought Conclusion or thoughts that consider all the evidence: The theory behind thought records is that clients assume their negative thoughts are true. Asking clients to examine the evidence for their thoughts stops their automatic reaction and starts a process of self-reflection. When clients examine the evidence for their thoughts and create their own balanced thought, they develop new ways of thinking and less extreme attitudes toward the world and them- selves. New ways of thinking open up the possibility of behavioral change. Evidence clearly shows that this process of cognitive restructuring is related to alleviating depression and anxiety (Beck & Dozois, 2011). A written thought record is not essential. Looking for the evidence for a thought can be done as part of a therapy conversation. However, I would encourage you to use the Understand Your Reaction and Examine the Reality of Your Thoughts worksheets as written tools. A written thought record pro- vides a structure and makes the process of identifying thoughts and looking for evidence very concrete. Some therapists like to use a seven-column thought record with space for identifying the four factors, looking for evidence, and developing a balanced thought. Dennis Greenberger and Christine Padesky use this type of thought record in their book Mind Over Mood (2016). Personally, however, I like to break the thought record down into two stages, first using the Understand Your Reaction worksheet and then the Examine the Reality of Your Thoughts worksheet. You can download both at http://www .newharbinger.com/38501. Although looking for evidence is a powerful intervention, looking for evidence once will not shift a longstanding negative thought. Your clients will need to complete many thought records, over a period of time, to change their negative thoughts. However, while a client’s thoughts vary somewhat from situation to situation, most clients have recurring negative thinking patterns. If you identify a cli- ent’s thoughts in one situation, most likely these thoughts will recur in other situations. This means that the thought record you complete for one situation will often be relevant to other situations. CHOOSE A HOT THOUGHT If your client has one central negative hot thought that is closely related to her emotional distress, that is the thought you will focus on. However, your client may have more than one hot thought, for example, I am an inadequate mother and My partner does not love me. In this case, your client needs to choose which thought to work with, as you can only examine the evidence for one thought at a time. If a client has more than one hot thought, I ask, “Which thought do you think is the most central, or the most important for us to examine?” Another question I have found helpful is, “Which thought do you think is most closely related to your strongest negative emotion?” Clients usually know which thought they need to focus on. Most of our negative thoughts are repetitive. If your client chooses to examine I am an inadequate mother, she will have another chance to examine My partner does not love me. WHAT IS SOCRATIC QUESTIONING? All CBT books talk about the importance of Socratic questioning. The term comes from the Greek philosopher, Socrates. Socratic questioning is the idea that skillful questioning can help your clients examine the assumptions behind their thoughts, consider aspects of the situation they had ignored, or understand their situation from a different perspective. Your role is to ask questions that help your client understand her problems in a new light. The basic idea is that it is more effective to ask questions that help clients reach their own conclu- sions than to tell a client what to think. If I could post one sticky note on all my readers’ heads, it would say: Conclusions you reach yourself are more convincing than conclusions someone tells you.

Agenda Item #2: Explain Looking for Evidence Once your client has identified a hot thought, you need to explain the idea of looking for evidence. Essentially, you are going to teach your client to examine her thoughts for their validity rather than treating thoughts as facts. Your client needs to learn to take a step back and put some distance between herself and her thoughts. My clients almost always immediately grasp the idea of looking for evidence, though sometimes they assure me that they know their negative thoughts are accurate. Here is how I usually explain looking for evidence (you can find a copy at http://www.newharbinger.com/38501): You did a really good job of identifying your thoughts and catching the negative thoughts that cause you to feel bad. I am wondering if you would be willing to examine your thoughts. I would like to look at the evidence that supports your negative thoughts, and also at evidence that doesn’t support your negative thoughts. Negative thoughts are like thought habits. By that I mean they are ways of thinking that you are used to, but you have not examined whether they are accurate. When we look for evidence, I want us to focus on facts. That way, we can evalu- ate the accuracy of your thoughts. Would that be okay with you? We need to pick one thought that we want to examine. I want to look over the thoughts you identified that go with your negative feelings and see if we can pick one that feels the most central to you, or is the most related to your strongest negative emotional reaction.  YOUR TURN! Practice in Your Imagination: Explain Looking for Evidence I want to ask you to imagine explaining looking for the evidence for a hot thought. Before you start, rate from 1 to 10 how comfortable you feel explaining looking for evidence for and against a hot thought. At the end of the exercise, rate your level of comfort again to see if it changed. Now, let’s try this exercise. Choose a client who you think would benefit from looking for evidence for his or her thoughts. Try to get a picture of him or her in your mind. Imagine yourself in your office with your client. See your office; notice the sounds and smells in the room. Imagine that your client has identified a negative thought and you want to explain how to examine the evidence for his thought. Read over how I suggest explaining the process of looking for evidence while imagining yourself saying the words. You can also use your own phrases. Really hear and feel yourself explaining how to examine the evidence. Now, imagine explaining looking for evidence two more times with the same client. Each time, imagine that your client responds positively.

Agenda Item #3: Find Evidence That Supports Negative Thoughts If you are going to help your client reevaluate her negative thoughts, you need to understand the evidence she uses to support them. Many clients find that writing down the evidence, or saying the evidence out loud, makes it more manageable. It becomes a fact that you can talk about, rather than something that sits in your head. Sometimes when a client starts to look for facts that support her nega- tive thoughts, she realizes that there aren’t any, or not as many as she thought. Sometimes a client discovers that her negative thoughts are fairly accurate. This can also be helpful, as it highlights the need to problem solve and cope with a real problem. SUZANNE EXAMINES THE EVIDENCE Let’s look at how we could help Suzanne with her anxiety about the invitation to the principal’s barbecue. She identified her hot thought as No one will want to talk to me. Suzanne’s therapist explained the process of looking at the evidence, and Suzanne was willing to try. Therapist:I want to start with looking for the evidence that supports your thought, No one will want to talk to me. What makes you think that it might be true? Suzanne:Well, I know that I will feel anxious when I go to the barbecue. Suzanne’s thought, I will feel anxious when I go to the barbecue, is not a fact. It is a prediction about how she will feel. Suzanne’s therapist wants to explore whether there are any facts that support her hot thought. Therapist:I hear you will feel anxious, but I wonder if there are any facts that support your belief that no one will want to talk to you. Suzanne:What do you mean? Therapist:If I wanted to prove that no one would want to talk to you, I would have to back up my opinion with facts. For example, if you were in a court of law, the judge would look only at the facts. Does that make sense to you? The therapist wants to be sure that Suzanne understands the idea of facts. Sometimes using the analogy of a court of law can be helpful. Suzanne:What about the fact that I hardly know any of the other teachers, does that count? Therapist:Of course, that is a fact. I wonder…how is it related to no one wanting to talk to you? Suzanne:Well, none of them have made an effort to talk to me. I usually stand alone at recess and I eat lunch by myself also. Therapist: Okay, so let’s write down what you just said, to be sure we don’t forget. How would you put that in your own words? (Either Suzanne or her therapist writes.) Other evidence that makes you think, No one will want to talk to me? Notice that Suzanne’s therapist is gathering data; she is not refuting or problem solving. Suzanne: I think it’s mainly at lunch and recess. Maybe also when I arrive in the morning, no one says hi to me, or smiles. USE THE PAST TO UNDERSTAND THE PRESENT It can be helpful to ask your client if she had any experiences in her childhood or past that support, or that are related to, her negative thoughts. Making the link between her history and her current thinking can help your client start to see that what was true in her past is not necessarily true in her current life. Take a moment to think about how you could ask Suzanne about the relationship between any past events and her hot thought. Therapist:Suzanne, is there anything in your past that would cause you to think, No one will want to be my friend? Suzanne:Actually, when I was in high school, in my last year, there was a group of really awful girls who made my life miserable. They wanted to use my house for a drinking party when my parents were away for the weekend, and I said no. They spread awful rumors about me, and I lost almost all my friends. It was a horrible, lonely time in my life. I felt then that no one wanted to be my friend. When a client discloses painful memories from her past, you need to decide if you want to focus on the memory or continue with the thought record. Generally, if it is the first time a client discloses a traumatic memory, I ask my client if she would like to focus on the memory. Suzanne disclosed a painful memory from high school that was upsetting, but not traumatic. Her therapist thought it was more important to continue with the thought record than to explore the high school memory. Therapist:It must have been very upsetting to have this happen. Is that when the thought No one wants to be my friend started? Suzanne:It was pretty awful. Yeah, that’s when I became more self-conscious and started worrying about people liking me. Before that, I just had a bunch of friends whom I hung out with. Therapist:It sounds like it really changed your outlook. In another session, it might be important for us to talk about what happened in high school. For now, could we just put it down in the “Evidence for” column? Let’s see how Suzanne filled in the “Evidence for My Thought” column of her Examine the Reality of Your Thoughts worksheet. Thought I want to examine: No one will want to be my friend. Evidence for My Thought Evidence Against My Thought • No one has made an effort to talk to me. • I am alone at recess and lunch. • Other teachers do not say hi when I get to school in the morning. • In high school, some girls started rumors and I lost almost all my friends. Agenda Item #4: Find Evidence Against Negative Thoughts Clients tend to focus on information that confirms their negative thoughts. Your job is to help your client focus on information she usually ignores and that challenges her negative thoughts. You can think of your client as living in a room filled with information, but only the information that supports her negative thoughts is lit; the rest of the room is in the dark. Your job is to use questions so that the whole room is in the light. Once the whole room is lit and your client sees all of the evidence, she can decide if her previous belief still makes sense. Figure 8.1 shows how a therapist used a drawing of lighting up a room to help her client Paula, who is a doctor, understand that she was only looking at information that confirmed her hot thought. In one of Paula’s therapy sessions she was very distressed and told her therapist she thought that she was not a good doctor. Her evidence for her belief was that this past week she had misdiagnosed a patient and another patient had been very angry because she had kept him waiting half an hour. Paula and her therapist looked at the evidence against her belief. Paula noted that she had been a successful doctor for twenty years, almost all her patients are happy, and she rarely keeps patients waiting; she also gave examples of many complicated diagnoses she made over the years. Her therapist drew figure 8.2 to help Paula understand that she only sees information that confirms her belief that she is a bad doctor, and that all of the information that suggests she is a good doctor is ignored or kept in the dark. Her therapist told Paula they had to shine a light on all of the information. Successful doctor for 20 years Patients rarely wait Most of my patients are happy Many complicated diagnoses One patient waited Misdiagnosed one patient Figure 8.1. Paula’s therapist shines some light on ignored information. There are three types of questions you can use to examine the evidence against a hot thought:

  1. Is there evidence that contradicts my negative thoughts?
  2. How probable is my negative prediction?
  3. Is there another perspective? EVIDENCE THAT CONTRADICTS YOUR CLIENT’S NEGATIVE THOUGHTS I generally start by directly asking my client if she has any experiences that suggest that her hot thought is not true, or not true all of the time. When Suzanne’s therapist asked, “Have you had any experiences that suggest that people may want to be your friend?” Suzanne responded quietly, “I had some friends in my previous school.” Evidence needs to be concrete and detailed. Examining the evidence for and against a negative auto- matic thought is similar to weighing evidence on a scale. On one side is the evidence for the negative thought and on the other side is the evidence against the negative thought. The evidence for the nega- tive thought is usually very heavy and full of details. The evidence against the negative thought is often more abstract and lacking in details. It can feel light compared to the heavy evidence for the thought. The more your client can provide detailed examples of evidence against the negative thought, the more she will be emotionally engaged, and the more the evidence against the negative thought will weigh compared with the evidence for it. Suzanne’s evidence against her hot thought is that she had “some friends.” This is not very strong or emotionally compelling evidence. To make the evidence more compelling, her therapist started by asking for specific examples, and then asked for details about the examples. Below are some of the ques- tions her therapist asked. •Can you give me examples of some of your friends? •When you say you had “some friends,” can you tell me about them? •What kinds of things did you do with your friends, both at school and outside of school? •How did you know that they wanted to be your friend? Her therapist discovers that Suzanne was friendly with many of the teachers at her previous school, but she had two good friends, Rita and Faiza. They generally ate lunch together and worked on the school play together. They often saw each other on weekends, and sometimes they would get together with their children and spouses. Suzanne thought they were funny, nice, warm people whom she had a good time with. Since she moved to her new school, she has seen less of them. They have often called to see if she wanted to do something on the weekend, but she’s been too tired. Faiza dropped by the other day with a cake she had made to cheer Suzanne up. What was the effect of making the evidence more concrete and detailed? Did it become more emotionally compelling? When her therapist explores the details of her friendship with Rita and Faiza, Suzanne’s mood lifts. When her mood lifts, she is also more likely to remember other situations that challenge her negative automatic thoughts. Figure 8.3 captures the idea of making the evidence heavier: when Suzanne’s evidence against her hot thought No one will want to be my friend becomes more detailed and concrete, it becomes more compelling. No one has made an effort to talk to me. I am alone at recess and lunch. Other teachers do not say hi in the morning. High school rumors, lost friends. I have some friends. EVIDENCE AGAINST EVIDENCE FOR No one has made an effort to talk to me. I am alone at recess and lunch. Other teachers do not say hi in the morning. High school rumors, lost friends. EVIDENCE FOR Friends with Rita and Faiza. Had lunch together. Worked on school play together. Hung out on weekends together. I have some friends. EVIDENCE AGAINST Figure 8.3. Weighing Suzanne’s evidence.  Exercise 8.1: Suzanne Is Upset with Her Husband Practice making evidence concrete and detailed.

ADDITIONAL QUESTIONS TO CHALLENGE YOUR CLIENT’S HOT THOUGHT Clients may need additional help to think of evidence against their hot thoughts. The following questions are inspired by a number of wonderful CBT therapists, including Judy Beck (2011), Dennis Greenberger and Christine Padesky (2016), and Jackie Persons and colleagues (2001). You can down- load a Questions to Identify Evidence Against Negative Thoughts handout at http://www.newharbin ger.com/38501. •What would you say to someone who thought this way? •What do you think a friend or someone who cared for you would say if he or she knew you had this thought? •If you were in a better mood, what would you think? •Five years from now, looking back, what might you think? •Is there any information that contradicts your interpretation? Even small pieces of information? •Is there any positive information that you are ignoring? Let’s see how Suzanne’s therapist uses some of these questions. Therapist:It sounds as if Faiza and Rita are really good friends. What do you think they would say if they knew you were thinking, No one will want to be my friend? Suzanne:They would say it was ridiculous. That of course people would want to be my friend. Her therapist wants to expand this evidence. Therapist: And if they really wanted to convince you, what might be some evidence they would tell you? Suzanne:Well, they would probably remind me of all the friends I had at my previous school; they would also remind me that they like me. Therapist:So they would remind you of your friends from your previous school and that they like you. And how is the fact that Rita and Faiza like you evidence against No one will want to be my friend? The therapist starts with a summary statement and then relates the evidence to the hot thought. Suzanne:(tentatively) Well I guess, if they like me, other people might like me? Therapist:(smiling) Do you think that might be true? Suzanne:(smiling) Yeah, I guess so.

Given that Suzanne’s mood has lifted a bit, she is more likely to remember other positive information. Therapist:I am wondering if there is any positive information that you are ignoring. Suzanne:(smiling) When I think of it, there is actually quite a bit. In college I had lots of good friends whom I still see, at least I saw them until I got depressed. I also have a bunch of friends from my neighborhood that I see on weekends, at the park. How could you expand the evidence that Suzanne just discussed? Remember, ask for an example and then ask for details. Suzanne’s evidence is starting to look very different! Thought I want to examine: No one will want to be my friend. Evidence for My ThoughtEvidence Against My Thought • No one has made an effort to talk to me.• I had some friends in my previous school. • I am alone at recess and lunch.• Rita and Faiza are good friends; ate lunch together; worked on the school play; hung out on weekends; went out as couples; still call to see if I want to do something; Faiza brought a cake. • Other teachers do not say hi when I get to school in the morning. • In high school, some girls started rumors and I lost almost all my friends. • Friends from college whom I still see • Friends from neighborhood Video 8.1: Looking for Evidence HOW PROBABLE ARE MY PREDICTIONS? Clients’ thoughts are often about the future and include negative predictions. Some examples might be No one will like me, I will fail the test, I will not get the job, or No one will like my Facebook post. When thoughts are about the future, you want to look for evidence about how likely it is that the nega- tive event will occur. Below are the steps I usually use.

  1. Identify what your client fears will happen, and make the list as concrete as possible.
  2. Rate the probability that each feared event will occur.
  3. Examine the evidence for the probability that each feared event will occur.
  4. Rerate the probability that each feared event will occur.

I often use the following worksheet, How Probable Are My Predictions?, which you can download a full-scale version of at http://www.newharbinger.com/38501. How Probable Are My Predictions? What I Fear Will Happen Probability Evidence That That Feared Supports the Event Will Probability Occur Evidence Against the Probability (0–100%) Rerate the Probability That Feared Event Will Occur Here is Suzanne’s list of what she feared would happen at the barbecue: •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, I will have nothing to say. •Clear image of standing next to the barbecue grill, looking very awkward, holding a glass in my hand, and being all alone as everyone else talks together. Rate the probability of each event occurring. Suzanne’s therapist asked her to rate from 0 to 100 percent how likely it was that each of these events would occur. Suzanne thought that the first three events, as well as her image, were very unlikely and rated them at 20 percent. Her therapist asked Suzanne to explain what made them unlikely. Suzanne laughed and said that it was a small group, and the principal would make sure everyone was talking to someone. She rated “having nothing to say” as probable, at 80 percent. Examine the evidence. Suzanne and her therapist looked at the evidence for “If I go up to one of the other teachers, I will have nothing to say.” Suzanne explained that when she was anxious, she some- times had difficulty finding something to talk about. This had happened at her husband’s holiday party.

When Suzanne and her therapist examined the evidence against her prediction, she was able to think of many examples when she had been able to find something to say at social events, even if it had been difficult. Even at her husband’s holiday party she had found something to talk about with her husband’s colleagues. Rerate the probability. After looking at the evidence, Suzanne rated the probability of having nothing to say at about 50 percent. Before and after probability ratings allow your client to see that there has been a decrease, even if the probability is not a 0. You can see how Suzanne and her therapist completed the How Probable Are My Predictions? worksheet at http://www.newharbinger.com/38501. Real and false alarms. Friedberg, Friedberg, and Friedberg (2001) have a wonderful exercise that helps clients look at whether their negative predictions actually occur. The therapist asks the client to list all of her worries for the coming week. The next week they check which worries actually happened. Most of the time, the majority of worries are “false alarms.” Tolerance of uncertainty. Unless your client’s negative predictions are totally bizarre, no one can guarantee that they will not occur. Clients need to learn to tolerate uncertainty (Dugas & Robichaud, 2007). This can be hard, but a first step is talking honestly with your clients about accepting that life is uncertain, and that while not impossible, the probability of the feared events occurring is small. Video 8.2: How Probable Are My Predictions? IS THERE ANOTHER PERSPECTIVE? Sometimes a client’s negative thought is based on an overly negative interpretation of an event; you want to help your client find a more benign interpretation. Let’s look at an example. Raoul was upset because a colleague walked past him in the hall without saying hello. Raoul thought this meant that his colleague was avoiding him. Another possible interpretation is that his colleague was in a hurry or preoccupied. Sometimes simply asking your client whether she can think of a different perspective is enough to start her thinking in a different way. However, sometimes you need to be more active. The following two approaches can help clients reach a more benign interpretation: (1) taking a close look at the facts of the situation and (2) exploring whether your client is blaming herself for something she has little or no control over. Take a close look at the facts. Clients tend to focus on narrow information that reinforces their thoughts; your job is to help your clients broaden their perspective and look at all of the facts of a situ- ation to see whether there is a more balanced interpretation. Do you remember in the last chapter Raoul was extremely upset that he had been assigned to work with junior colleagues on a report? He was sure this meant that his boss did not respect him. Below are questions you can use to help your client examine her interpretation of a situation. You can download a Questions to Gather More Information about the Situation handout at http://www.newharbinger .com/38501. •How did this situation come about? •Who are the other people you will be working/interacting with? •Is there any information that contradicts your interpretation? Even small pieces of information? •Is there any positive information that you are ignoring? •Have you ever behaved in a similar way? What was your motivation? Let’s see what happens when Raoul’s therapist uses these questions to explore Raoul’s interpreta- tion of the situation. Questions to Gather More Information about the Situation QuestionsRaoul’s Response How did this situation come about?My boss approached me and said he would like me to work on this report, as he thought I had the needed expertise and had done this kind of work before. Who are the other people you will be working/ interacting with?Two junior colleagues, who have been hired in the past two years. Is there any information that contradicts your Often senior people are asked to work with more interpretation? Even small pieces of information? junior people on reports. It is pretty common in the firm. Is there any positive information that you are ignoring?One of the junior people told me she was really glad to have me on the team, that she had heard great things about me. Have you ever behaved in a similar way? What was your motivation?In the past, I assigned a senior person to work on a project, to be sure that there was someone with the needed expertise on the project. Raoul’s therapist asked him whether this additional information had any implications for his thought that being assigned to the project meant that his boss did not respect him. Raoul replied that it might mean they wanted a senior person on this project. I am looking for a crack in my client’s beliefs. Just like water seeping through a stone, if you can get a small crack, it can spread.

Your Turn! Help Suzanne Take a Close Look at the Facts Suzanne was very distressed that none of the teachers talked to her at recess. This was a key piece of evidence in her belief that no one would want to be her friend. Her therapist thought it would be worth- while to see if there was a more benign interpretation. Therapist: One of the pieces of evidence you use to support your belief that none of the teachers would want to be your friend is that no one talks to you at recess. Look at the three possible responses below and pick the one that will help Suzanne start to gather facts about the situation.

  1. It seems strange to me that they don’t talk to you; they sound like horrible people.
  2. How could you join one of the groups of teachers?
  3. Can you describe to me what happens at recess, what the other teachers do, and what you do? Response #3 is the best question to help collect information on what occurs at recess. Depending on the answer, the therapist can follow up in different ways. Response #1 supports Suzanne’s interpreta- tion of the situation. Response #2 starts a problem-solving process before the problem is clarified. Therapist: Can you describe to me what happens at recess and what the other teachers do? Suzanne: We each have an area we are responsible for. Actually, when I think of it, only the two teachers who are assigned to the jungle gym stand together. The rest of us stand alone in the school yard. Some of the other teachers might approach each other and say a few words. I just stand in the back of the school yard next to the swings. Look at the three possible responses below and pick the one that will help Suzanne start to gain a different perspective.
  4. I hear that everyone is assigned to an area and that most of the teachers are standing alone; do I have it right?
  5. How much of a discipline problem are the children? What kinds of things do you find help with maintaining order?
  6. It seems to me that everyone is alone, and it doesn’t mean they don’t want to talk to you. Response #1 is the best response. It is a summary of what Suzanne has told her therapist and is most likely to encourage her to consider a different perspective on what standing alone at recess means. In response #2, the therapist is gathering data about the situation, but the data is not relevant to Suzanne’s thought, No one wants to be my friend. In response #3, the therapist is telling Suzanne what to think.

Video 8.3: Take a Close Look at the Facts Is your client blaming herself for something she has little or no control over? Many clients feel responsible for situations they have no control over or believe that the situation is a reflection of them- selves, when it is at least partially due to external factors. Two of the questions I find most helpful are:

  1. Are there other factors that could contribute to this situation?
  2. Am I blaming myself for something I have little or no control over? Let’s look at some examples of clients’ thoughts and see if there are other ways of looking at the situation. You can download a Other Ways of Understanding the Situation worksheet at http://www .newharbinger.com/38501. Other Ways of Understanding the Situation SituationClient’s ThoughtAre there other factors that could contribute to this situation? List all of the factors.What can I control? Am I blaming myself for something I have little or no control over? Client’s 16-year- old son is using marijuanaI am a bad mother.Many factors contribute to a child using marijuana, including availability, peer group, and laws.I can control telling my child not to use marijuana, but there are many other factors that contribute to marijuana use. Yes, I am blaming myself for something I do not have complete control over. Only 15 people came to my talk at the confer- ence; many people had over 25 at their talks. My work is not interesting or important. My talk was at the end of the day; it was a beautiful day outside; there were other similar talks at the same time. I can control how much work I put into my talk. I cannot control when my talk is scheduled or the weather. Yes, the other factors would also impact how many people came.

HELP YOUR CLIENTS REACH THEIR OWN CONCLUSIONS Sometimes you remember information that challenges your client’s negative thought, but your client does not think of the information. Should you just tell your client? Let’s go back to the basic principles of Socratic questioning. You want to ask questions that draw your client’s attention to infor- mation she is not thinking about. Once your client has the information, you want her to draw her own conclusion. For example, Raoul tells you that he has stopped contributing to meetings because he believes that “no one is interested in my comments.” You remember that a few weeks ago Raoul described making a comment in a project meeting, to which one of his colleagues responded, “That is the best solution anyone has suggested so far.” You could remind Raoul of his colleague’s comment and then tell Raoul that clearly people are interested in what he has to say. However, it is more effective if Raoul can reach his own conclusions. It is better to ask Raoul if he remembers what his colleague said, and then once Raoul has told you, ask him what his colleague’s statement might mean about his thought, No one is interested in my comments. YOUR TURN! Help Cynthia Reach Her Own Conclusions Cynthia was in therapy because she was having trouble with low self-esteem that was affecting many different areas of her life. She tells her therapist, “I was so embarrassed. I was at a party and a guy I know from work kept hitting on me. He kept telling me he wanted to go out with me and that I was beautiful. I just kept ignoring him. Men are only interested in me for sex.” Cynthia’s hot thought is Men are only interested in me for sex. Cynthia’s therapist tells her, “You are a wonderful woman; you deserve to find a great man. You have told me that lots of your male colleagues like and respect you.” Instead of telling Cynthia what to think, what questions could the therapist ask that would help Cynthia reach her own conclusions? From previous sessions her therapist knows that Cynthia is dating John, who frequently tells her that he cares about her. John always checks that she also wants sex before they have sexual relations. Cynthia has also talked about male colleagues who made comments indicating they respect Cynthia, especially Mike and Chris, whom she works closely with. Your job is to think of questions that you could ask to help Cynthia reach her own conclusion about whether men are only interested in her for sex. You can find my suggestions in the appendix.  Exercise 8.2: A Therapist Is Having a Bad Day Practice developing questions to help your clients reach their own conclusions.  Exercise 8.3: Suzanne Is Asked to Be a Maid of Honor Practice using a therapy dialogue to help clients reach their own conclusions.

CONSOLIDATE THE EVIDENCE AGAINST THE HOT THOUGHT Most likely your client is used to thinking about the information that supports her negative thoughts and tends to minimize the information against her negative thoughts. If you want your client to emo- tionally connect to the information against her negative thought, it is important to review the informa- tion. Reviewing focuses your client’s attention on this information and starts to create new thought habits. Usually I simply say, “Let’s review the information we have gathered.” If you have not written down the evidence, this is a good time to do so. You can say, “You collected some very important evidence about your thoughts. I think it would be helpful if we wrote it down, to be sure that we don’t forget it.” I encourage my clients to do the writing, as I think it helps with the review process. (If I am doing the writing, I repeat out loud what I am writing.) This also provides the client with a piece of paper she can take home and review as part of homework. You can also use imagery to help evidence against a hot thought come alive (Josefowitz, 2016) by asking your client to form an image in her mind of the memories and situations that constitute the evidence against the hot thought. For Suzanne, an important piece of evidence against her hot thought was eating lunch almost every day with Rita and Faiza at her previous school. Her therapist asked Suzanne to form an image in her mind of eating lunch with her friends. She asked Suzanne to remem- ber the lunchroom, the fun of being together, and how much they liked each other. Her therapist then went over the rest of the evidence, asking Suzanne to form an image for each example. When they had finished, the evidence felt much more real and emotionally engaging. Agenda Item #5: Develop Balanced Thoughts The final step in completing a thought record is evaluating the original hot thought and creating a new more balanced thought that takes all of the evidence into account. This is when you fill in the “Conclusion” section of the Examine the Reality of Your Thoughts worksheet. The basic question is, “Given all of the evidence, is your hot thought accurate, or does it need to be modified?” Here are some questions I regularly use. You can find Questions for a Balanced Thought at http://www.newharbinger .com/38501. •When you look at all of the evidence, what does this say about your original hot thought? •When you look at all of the evidence, what would be a more accurate thought? •What might be a thought that captures all of the evidence? •Let’s take a moment and look at all of the evidence. What did you learn? •You initially interpreted the situation in a specific way. When you look at the evidence, is there another interpretation that either makes more sense or might be equally true? •What would you tell someone who thought the way you did, and had all of this evidence? Let’s look at how Suzanne initially completed the Understand Your Reaction worksheet and the Examine the Reality of Your Thoughts worksheet. Then, let’s look at the evidence that Suzanne and her therapist collected.

SituationFeelingPhysical ReactionBehaviorThoughts Principal invited me to barbecue with the three other new teachersNervous (7)Clenched stomach (4)Did not respondI don’t want to go; 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. Worried (8) Embarrassed (6) Tense shoulders (5) Image: Standing alone in backyard as other teachers talk HOT THOUGHT: No one will want to be my friend. Thought I want to examine: No one will want to be my friend. Evidence for My ThoughtEvidence Against My Thought • No one has made an effort to talk to me.• I had some friends in my previous school. • I am alone at recess and lunch.• Rita and Faiza are good friends; ate lunch together, worked on the school play; hung out on weekends; went out as couples; still call to see if I want to do something; Faiza brought a cake • Other teachers do not say hi when I get to school in the morning. • In high school, some girls started rumors and I lost almost all my friends. • Friends from college whom I still see • Friends from the neighborhood Try to think of a balanced thought that captures all of the evidence. Write it down so you can compare it to the one Suzanne came up with. Therapist:It seems to me that when you think, No one will want to be my friend, you are only consider- ing the evidence that supports your thought. What happens when you consider all of the evidence? Suzanne:I guess that it doesn’t seem to be so true. Therapist:In what way is it not so true? Suzanne:Well, I do have friends who like me and want to be my friend. I think one of the problems is that I have been avoiding my friends from my old school. Therapist:I think you are right; we discovered that you have quite a few friends who like you. What would be a thought that captures all of the evidence? Suzanne:Well, I guess, even though I haven’t yet made friends at my new school, I had friends in the past and there really is no reason I won’t have friends in the future. Is Suzanne’s balanced thought better than the one you came up with? My clients often come up with far better balanced thoughts than I could ever have “told” them. Your job as a therapist is now easy—you just need to reinforce and consolidate the balanced thought. There are two tasks left before completing the thought record. First, ask your client how much she believes the thought from 0 to 100 percent. Even if she gives a fairly low score, it is still a start to believ- ing a new balanced thought. Second, ask your client if she believed the balanced thought, how would this affect her feelings, and ask her to rerate her original feelings. Suzanne believed her balanced thought 75 percent. She rerated her feelings Nervous: 5, Worried: 5, and Embarrassed: 4. CONSOLIDATE THE BALANCED THOUGHT You have just spent a great deal of time and effort creating a balanced thought. It is worth spending a bit more time to consolidate this thought. First, be sure to smile and express interest in your client’s balanced thought. Your enthusiasm is reinforcing. Second, review the balanced thought in as many ways as you can. Here are some suggestions. •Say the balanced thought out loud and add a compliment. For example, I might repeat the balanced thought and say, “I like the way the balanced thought captures all of the evidence.” •Ask your client if she would like to write down the balanced thought so that she can remember it. My clients have written their balanced thoughts on coping cards, kept the balanced thoughts on their phones, or made the balanced thought into their screen saver. •Ask your client to repeat the balanced thought out loud. Depending on the balanced thought, I might ask my client to try a more assertive tone, or a more compassionate, gentle tone. •Ask your client to regularly review the balanced thought. I find it helpful to specify a set time to review, such as first thing in the morning. Develop a metaphor or an image. Often a balanced thought is fairly long and complex and can be hard to remember. It can be helpful to create an image of the evidence that is the most compelling for your client and attach it to the balanced thought. An image that symbolizes the balanced thought, a metaphor, or even a shortened version can increase the emotional strength of the balanced thought and make it more memorable (Hackmann et al., 2011; Josefowitz, 2017). Here is Suzanne’s shortened version of her balanced thought: Hang in there, you will make friends again. Exercise 8.4: Suzanne Reviews Her Balanced Thought Practice reviewing a balanced thought. Video 8.4: Create Balanced Thoughts USE BALANCED THOUGHTS TO CREATE A NEW IMAGE When Suzanne’s therapist initially asked her about her thoughts and images, Suzanne reported that she had an image of herself alone in the principal’s backyard while the other teachers talked to each other. Once you have examined the evidence against the hot thought and created a balanced thought, you can go back and directly modify your client’s original image. Given the close connection between imagery and emotion, this can be a very powerful intervention. Let’s see how Suzanne’s thera- pist helps her create a new image. Therapist:You started out with a very clear image of yourself standing in the principal’s backyard, awkward and alone, as the other teachers talked together. Suzanne:That’s right, I wasn’t even aware that I had that image until you asked. Therapist:Given the evidence that we just looked at, and your balanced thought, how accurate do you think your original image is? Suzanne:(laughing softly) Probably not accurate at all. Therapist:I think it would be really helpful if we could develop a more realistic image of what you think will happen. Could we try? Suzanne:When I look at the evidence, and I really think about it, a more realistic image would be of my standing in the principal’s backyard talking to the other teachers, or at least being part of the group, even if I am not talking. Suzanne’s therapist thought this was a good start for a new image. However, the initial negative image was very detailed and vivid. Suzanne’s therapist wanted the new image to be as compelling. Therapist:Can you tell me a little bit more about this new image? Suzanne:Well, I see myself standing there with my drink, and I am part of a small group. I am listen- ing as one of the other teachers says something. Therapist:Can you get a clear picture in your mind of this new image? Suzanne:Yes, I can see it clearly (smiling). Therapist:And how do you feel when you get this image? Suzanne:A lot more relaxed about going, and a lot less depressed. Almost makes me wonder if it could be a good experience. After they had developed this new image, Suzanne’s therapist asked her to consciously practice seeing the new image three times a day. They discussed specific times that Suzanne could practice. Her therapist told Suzanne that the practice could be very short, even a few minutes, but it was important to practice regularly. USE BALANCED THOUGHTS TO MANAGE STRESS Balanced thoughts generally move your client away from extreme thinking, such as No one will like me, to more balanced thinking that generally helps with anxiety and depression as well as self-esteem. Balanced thoughts provide a more resilient attitude toward life’s stressors. As we discussed earlier, most clients have typical negative thoughts that tend to recur. This means that the balanced thoughts you develop for one situation will most likely also be relevant to other situations. When Suzanne’s therapist asked if there were other situations where she had the thought No one will want to be my friend, Suzanne said she had this thought “all the time.” Her therapist asked for examples, and Suzanne replied that she often had these thoughts when she was alone at school during recess and lunch and at the end of the day when she left without saying good-bye to anyone. If you look at all of these situations, the thought No one will want to be my friend leads to Suzanne feeling depressed and withdrawing from the other teachers, making it almost impossible to make friends, leading to a vicious cycle where it seemed true that no one wanted to be her friend. Suzanne’s therapist asked her, “Instead of thinking, No one will want to be my friend, if you thought your new balanced thought, Hang in there, you will make friends again, how do you think you would feel?” Suzanne smiled as she responded that she would be less depressed. Suzanne and her therapist problem solved how she could remember her new balanced thought in the other situations when she starts thinking, No one will want to be my friend. Suzanne’s therapist also encouraged her to notice if she had any unrealistic images in these situations. Sometimes, completing a thought record influences how your client wants to behave. After Suzanne developed a balanced thought, she turned toward her therapist and said, “I have been really silly about the barbecue. I would like to go. It would be good to meet the other teachers, and there is no reason to be so anxious.” Let’s see how Suzanne’s therapist could help her use her balanced thought. Therapist:When you think about it, you would like to go to the barbecue. Suzanne:I think it would be a good thing to do. I want to make friends at my new school, and it’s just silly to avoid social events because of my anxiety. Therapist:After we did the thought record, you came up with a really good balanced thought; do you remember what it was? Suzanne:Yes, it was, Hang in there, you will make friends again. Therapist:That’s right. I am wondering if you could remember your balanced thought when you think of going to the barbecue, if that would help with your anxiety. Suzanne:I think it would. Therapist:Sounds like a great plan.

CHECKLIST OF COMMON PROBLEMS WITH THOUGHT RECORDS Thought records are generally an effective intervention; however, some are more helpful than others. Below is a checklist you can use to check that a thought record is well done. You can find a copy of Checklist of Common Problems with Thought Records at http://www.newharbinger.com/38501. G* Is the situation a factual description of what occurred? G* Did my client identify and rate his or her feelings? G* Did my client identify his physical reactions? G* Is the behavior a factual description of what my client did? G* Is the thought my client wants to focus on a hot thought? G* Is the thought about self, others, or the future? G* Is the thought related to his or her negative feelings? G* Does the evidence against address the hot thought? G* Does the balanced thought address the hot thought? It is important that the evidence you gather challenge the hot thought you are working on. For example, a colleague had passed Raoul in the hall and had not said hi. Raoul thought, My colleague is avoiding me. His evidence against his thought was, My bowling buddies are happy to see me. This evi- dence will help Raoul feel better, but it is not related to the thought, My colleague is avoiding me. In this situation you need to keep exploring Raoul’s thoughts using Questions to Identify Evidence Against Negative Thoughts to find evidence related to the hot thought you are working on. It is equally important that the balanced thought directly address the hot thought. For example, if the original thought was about self, the balanced thought needs to be about self; if the original thought was about others, the balanced thought needs to be about others. When Raoul was assigned to work with junior colleagues, his original thought was My boss doesn’t respect me. After examining the evi- dence for and against, his initial balanced thought was I work very hard and do a good job. This is a generally helpful thought that will increase Raoul’s positive mood. If I were his therapist, I would be delighted that he was able to have such a positive thought about himself. However, the hot thought was about others (his boss), and the balanced thought needs to also be about others. A better balanced thought would be, Even though I was asked to work with junior colleagues, this does not mean my boss does not respect me. There is a lot of evidence that my boss still respects me and my work. It is helpful to keep this list in mind when examining your clients’ thought records. Take a moment after your session is over and on your own review your client’s thought record, using the checklist. After you have used it a few times, it will become second nature.  Exercise 8.5: Common Problems with Thought Records Practice using the checklist for identifying common problems in thought records.

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 8.1: Suzanne Is Upset with Her Husband Exercise 8.2: A Therapist Is Having a Bad Day Exercise 8.3: Suzanne Is Asked to Be a Maid of Honor Exercise 8.4: Suzanne Reviews Her Balanced Thought Exercise 8.5: Common Problems with Thought Records Apply What You Learned to Your Own Life I think you only become a committed CBT therapist when you experience how helpful it can be to identify your own negative thoughts, step back and examine the evidence, and then develop a balanced thought. Homework Assignment #1 What Is the Evidence? This coming week, when you have a strong emotional reaction, try to identify the situation, identify and rate your feelings, and then identify your thoughts. Choose one thought to examine using Questions to Identify Evidence Against My Negative Thoughts. Record your answers on the following worksheet.

Examine the Reality of Your Thoughts Thought I want to examine: Evidence for My Thought Evidence Against My Thought Conclusion or thoughts that consider all the evidence: Homework Assignment #2 How Probable Is My Prediction? This coming week when you are anxious, notice your negative predictions. Rate the probability that each will occur, look at the evidence, and then rerate the probability. Try to use the How Probable Are My Predictions worksheet.

Homework Assignment #3 Is There Another Interpretation? This coming week when you are upset by what someone did to you or by a situation, ask yourself if there is a more benign interpretation. Ask yourself if you are considering all of the facts of the situation. Are you blaming yourself for something you have no control over? Try to use the Other Ways of Understanding the Situation worksheet. Apply What You Learned to Your Therapy Practice It is time to start asking your clients to examine the evidence for their thoughts. Try to help a client identify her trigger situation and then identify and rate her feelings and thoughts. Once you have iden- tified a central thought, introduce the idea of looking for evidence and use the Questions to Identify Evidence Against My Negative Thoughts. Make sure that the evidence is concrete and addresses the hot thought. Use the Examine the Reality of Your Thoughts worksheet to record your client’s responses. Let’s Review Answer the questions under each agenda item. Agenda Item #1: What are thought records? • What are the essential steps in a thought record? Agenda Item #2: Explain looking for evidence. • How could you introduce looking for evidence to your clients? Agenda Item #3: Find evidence that supports negative thoughts. • Why is it important to look for facts that support negative thoughts? Agenda Item #4: Find evidence against negative thoughts. • What are three questions that will help gather information against a client’s negative thoughts? Agenda Item #5: Develop balanced thoughts. • How could you consolidate a balanced thought?

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.)

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