Layers of Thoughts

In CBT, identifying, questioning, and challenging your thoughts is complicated by the fact that a lot of thinking happens below the surface of conscious awareness. In fact, the cognitive model describes layers of cognition that are sometimes compared to the layers on an onion: peeling back the outer layers reveals the layers underneath. Using this metaphor, your conscious thoughts make up the skin on the outside of the onion. These are the thoughts you are most aware of at any particular moment – the thoughts in the forefront of your mind that make up your ongoing stream of consciousness. They include things that you are paying attention to, focusing on, or choosing to think about. 

Just underneath your conscious thoughts is a layer of what are known as “automatic thoughts.” As the name implies, these thoughts happen automatically – without conscious deliberation. They are typically judgments or evaluations, and are generally brief – sometimes only a few words or a mental image. Automatic thoughts happen so quickly that we are barely aware of them; however, they are relatively easy to bring into conscious awareness because they often produce a shift in mood or emotion. You can become aware of your automatic thoughts by noticing changes in how you feel, and asking yourself: “What was just going through my mind?” 

Automatic thoughts, in turn, give us clues about the interior layers of the onion – our intermediate and core beliefs. Beginning in early childhood, we develop beliefs about ourselves, other people, and the world we live in. Some of these beliefs are so fundamental to how we view everything that we see them as absolute truths. We call these "core beliefs." Core beliefs are the basic assumptions that determine to what degree you see yourself as worthy/unworthy, safe/threatened, competent/incompetent, powerful/vulnerable, independent/dependently, and loved/unlovable. They also establish your sense of belonging and how you expect to be treated by others. 

Although we are often not consciously aware of our core beliefs, they have a significant impact on us: situations in daily life activate core beliefs, which then shape our perception and interpretation of the situation. The way that core beliefs influence our perception, interpretation, and response to a situation is through what are called "intermediate beliefs." These include our attitudes, assumptions, and rules. Attitudes are evaluative statements (e.g., "It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "should" (or must, or ought) statements. Intermediate beliefs arise from core beliefs, either as logical extensions of them, or as attempts to cope or compensate for what we believe is true, for example: “I am inadequate so I need to work harder than everyone else.” “I am unlovable, so I should expect rejection.” 

Core beliefs can be combined in patterns called “schemas,” along with associated intermediate beliefs, and the emotions, body sensations, and behaviors they produce. Schemas serve as templates for processing and understanding life experiences, filtering incoming information so that we take in information that fits our existing core beliefs, while screening out anything that contradicts our beliefs. Schemas also shape the content of conscious and automatic thoughts. Automatic thoughts, in turn, strengthen and reinforce beliefs: the more you “hear” yourself think something, the more convinced you are that it is true. These processes together make core beliefs difficult to change. However, the time and effort needed to change them has a significant payoff: the resulting changes to intermediate beliefs and automatic thoughts can produce lasting emotional and behavioral benefits.

Core Beliefs and Schemas

We all develop beliefs about ourselves, other people, and the world we live in, beginning in early childhood. Some of these beliefs are so fundamental to how we view...everything...that we see them as absolute truths. We call these "core beliefs." Core beliefs are your basic assumptions about your value in the world. Core beliefs determine to what degree you see yourself as worthy, safe, competent, powerful, independent, and loved. They also establish your sense of belonging and basic picture of how you are treated by others.

We may not be consciously aware of our core beliefs - they are kind of like the water fish swim in. However, they have a significant impact (like water does for fish): situations can activate core beliefs, which then shape our perception and interpretation of the situation. In fact, we tend to filter incoming information to accept information that fits the core belief, while discounting anything that contradicts our belief.

The way that core beliefs influence our perception, interpretation, and response to a situation is through what is called "intermediate beliefs." This category includes our attitudes, assumptions, and rules. Attitudes are evaluative statements ("It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "shoulds" (or musts, or oughts). These intermediate beliefs arise from core beliefs, either as logical extensions thereof, or as attempts to cope with a painful core belief (often that one is inadequate and/or unlovable): I am inadequate so I need to work harder than everyone else. I am unlovable, so I should expect rejection. Etc.

Both kinds of beliefs shape the content of your thoughts from moment to moment – your internal monologue, or “automatic thoughts.” Automatic thoughts, in turn, strengthen and reinforce your beliefs. For example, when you tell yourself constantly that you’re stupid, you convince yourself that this is true. By the same token, if your self-statements reflect a basic faith in your intelligence, this core belief will be confirmed and solidified.

As you can see, core beliefs are the very foundation of your self-image: they largely dictate what you may and may not do (your rules), how you present yourself (your attitude) and how you interpret events in your world (your assumptions and automatic thoughts). Therefore, holding negative beliefs takes a significant toll on your mood, relationships, and overall functioning. Changing your core beliefs requires time and effort; and yet changing them will fundamentally alter your view of yourself and your environment.

Schemas

Core beliefs are also combined in patterns that are referred to as schemas. Schemas include beliefs about yourself, the future, other people and the world, along with associated intermediate beliefs (now called schema processes), which produce emotions, body sensations, and behaviors. Schemas form templates for processing and interpreting life experiences.

Dr. Young and his colleagues have identified 18 “early maladaptive schemas:” schemas that develop very early in life and can produce distress and difficulties throughout one’s life. Read through their list of schemas and rate how strongly you think each one applies to you, from 0-100%.

Emotional Deprivation
This schema refers to the belief that one’s primary emotional needs will never be met by others. These needs can be described in three categories: Nurturance – needs for affection, closeness and love; Empathy – needs to be listened to and understood; and Protection – needs for advice, guidance and direction. Generally parents were cold or removed and didn’t consistently care for the child in ways that would adequately meet the above needs.

Abandonment/Instability

This schema refers to the expectation that one will soon lose anyone with whom an emotional attachment is formed. The person believes that, one way or another, close relationships will end imminently. As children, they may have experienced the divorce or death of parents. This schema can also arise when parents have been inconsistent in attending to the child’s needs; for instance, there may have been frequent occasions on which the child was left alone or unattended to for extended periods.

Mistrust/Abuse

This schema refers to the expectation that others will intentionally take advantage in some way. People with this schema expect others to hurt, cheat, or put them down. They often think in terms of attacking first or getting revenge afterwards. In childhood, these people were often abused or treated unfairly by parents, siblings, or peers.

Defectiveness/Shame

This schema refers to the belief that one is internally flawed, and that, if others get close, they will realize this and withdraw from the relationship. This feeling of being flawed and inadequate often leads to a strong sense of shame. Generally parents were very critical and made them feel as if they were not worthy of being loved.

Social Isolation/Alienation

This schema refers to the belief that one is isolated from the world, different from other people, and/or not part of any community. This belief is usually caused by early experiences in which children see that either they, or their families, are different from other people.

Dependence/Incompetence

This schema refers to the belief that one is not capable of handling day-to-day responsibilities competently and independently. People with this schema often rely on others excessively for help in areas such as decision-making and initiating new tasks. Generally, parents did not encourage children to act independently and develop confidence in their ability to take care of themselves.

Vulnerability to Harm and Illness

This schema refers to the belief that one is always on the verge of experiencing a major catastrophe (financial, natural, medical, criminal, etc.). It may lead to taking excessive precautions to protect oneself. Usually there was an extremely fearful parent who passed on the idea that the world is a dangerous place.

Enmeshment/Undeveloped Self

This schema refers to a pattern in which a person experiences too much emotional involvement with others – usually parents or romantic partners. It may also include the sense that one has too little individual identity or inner direction, causing a feeling of emptiness or of floundering. This schema is often brought on by parents who are so controlling, abusive, or overprotective that the child is discouraged from developing a separate sense of self.

Failure

This schema refers to the belief that one is incapable of performing as well as one’s peers in areas such as career, school or sports. These clients may feel stupid, inept or untalented. People with this schema often do not try to achieve because they believe that they will fail. This schema may develop if children are put down and treated as if they are a failure in school and other spheres of accomplishment. Usually the parents did not give enough support, discipline, and encouragement for the child to persist and succeed in areas of achievement, such as schoolwork or sport.

Subjugation

This schema refers to the belief that one must submit to the control of others in order to avoid negative consequences. Often these people fear that, unless they submit, others will get angry or reject them. They therefore ignore their own desires and feelings. In childhood there was generally a very controlling parent.

Self-Sacrifice

This schema refers to the excessive sacrifice of one’s own needs in order to help others. When these people pay attention to their own needs, they often feel guilty. To avoid this guilt, they put others’ needs ahead of their own. Often people who self-sacrifice gain a feeling of increased self-esteem or a sense of meaning from helping others. In childhood the person may have been made to feel overly responsible for the wellbeing of one or both parents.

Emotional Inhibition

This schema refers to the belief that one must suppress spontaneous emotions and impulses, especially anger, because any expression of feelings would harm others or lead to loss of self-esteem, embarrassment, retaliation or abandonment. These people may lack spontaneity, or be viewed as uptight. This schema is often brought on by parents who discourage the expression of feelings.

Approval-Seeking/Recognition-Seeking
This schema refers to the placing of too much emphasis on gaining the approval and recognition of others at the expense of one’s genuine needs and sense of self. It can also include excessive emphasis on status and appearance as a means of gaining recognition and approval. People with this schema are generally extremely sensitive to rejections by others and try hard to fit in. Usually they did not have their needs for unconditional love and acceptance met by their parents in their early years.

Unrelenting Standards/Hyper-criticalness
This schema refers to the belief that whatever you do is not good enough, that you must always strive harder. The motivation for this belief is the desire to meet extremely high internal demands for competence, usually to avoid internal criticism. People with this schema show impairments in important life areas, such as health, pleasure or self-esteem. Usually these clients’ parents were never satisfied and gave their children love that was conditional on outstanding achievement.

Entitlement/Grandiosity
This schema refers to the belief that one should be able to do, say, or have whatever one wants immediately, regardless of whether that hurts others or seems reasonable to them. These people are not interested in what other people need, nor are they aware of the long-term costs of alienating others. Parents who overindulge their children and who do not set limits about what is socially appropriate may foster the development of this schema. Alternatively, some children develop this schema to compensate for feelings of emotional deprivation or defectiveness.

Insufficient Self-Control/Self-Discipline
This schema refers to the inability to tolerate any frustration in reaching one’s goals, as well as an inability to restrain expression of one’s impulses or feelings. When lack of self-control is extreme, it may lead to criminal or addictive behaviors. Parents who did not model self-control, or who did not adequately discipline their children, may predispose them to this schema as adults.

Negativity/Pessimism
This schema refers to a pervasive pattern of focusing on the negative aspects of life while minimizing the positive aspects. Clients with this schema are unable to enjoy things that are going well in their lives because they are so concerned with negative details or potential future problems. They worry about possible failures no matter how well things are going for them. Usually these people had a parent who worried excessively.

Punitiveness
This schema refers to the belief that people deserve to be harshly punished for making mistakes. People with this schema are critical and unforgiving of both themselves and others. They tend to be angry about imperfect behaviors much of the time. In childhood these clients usually had at least one parent who put too much emphasis on performance and had a punitive style of controlling behavior.

Based on:

Time-Limited Treatment

CBT, and some other models of treatment, advocate for beginning therapy with predetermined time limits. For example, manualized CBT for Eating Disorders involves 20 sessions for most clients, and 40 for markedly underweight clients. The authors of the manual discourage extending treatment except to compensate for disruptions in treatment due to life crises, etc., or in cases where there are symptoms that "continue to interfere significantly with the patient's functioning and are unlikely to resolve on their own." That means that treatment may end even in the presence of continued symptoms, as long as the client is making progress.

There are a few reasons given for this approach.

1) Having a set time-limit from the beginning creates and maintains momentum throughout treatment, by putting pressure on both therapist and client to make the most of the time they have.

2) Ending treatment before symptoms have completely abated, assuming that the symptoms will continue to improve naturally without further intervention, based on the treatment already provided, serves to foster client self-confidence, and reduce dependence on therapy or therapist.

3) Scheduled endings are more likely to be planned rather than unexpected, which allows necessary time to be spent consolidating gains and engaging in relapse prevention.

Of course, advocating a time-limit requires determining how many sessions over what period of time is most efficacious for various client groups with various presenting problems. It also does not address the possibility of multiple comorbid conditions that influence each other and cannot be separated to address sequentially. There are probably other potential logistical difficulties as well.

I find myself somewhat dubious of this sort of predetermined time limit, but can see why it makes sense to some theorists and clinicians; I just have not had enough experience with time-limited formats to make an educated comparison. Have you had experience with both time-limited and ongoing treatment formats? If so, what do you see as the benefits and drawbacks of each?

It's Just a Thought

Periodically, the agency I work for invites a former patient who wrote a book about her recovery to come speak to current patients. She talks about what it was like for her to have an Eating Disorder, and how she recovered. 

For various reasons, the presentation tends to get mixed reviews. The main concern it raises for me is that the speaker presents recovery in rather black-and-white terms: she claims that, since she is recovered, she never has a single thought or impulse to engage in eating-disordered behavior. Never. Not even when she was going through a divorce.

That sounds great, right? I imagine she might think it is a way of holding out hope for patients that they can truly recover. However, I worry that it could have the opposite effect: they may come to believe that "true recovery" means never having a thought or impulse. And because most (if not all) people in recovery may have a passing "disordered" thought or impulse from time to time, this belief is neither realistic nor helpful.

The truth is that these kinds of thoughts may happen - but having the thought does not mean one is no longer "in recovery." It's normal - to be expected after years of habitually having such thoughts. Recovery does not depend on whether or not you have certain thoughts, but rather what you do with them. Learning that thought does not have to become action is crucial in early recovery, and learning that thought need not lead to action is crucial for relapse prevention. It would be much more helpful for patients to hear that someone can have these thoughts and not be fazed by them - recognize them as "just thoughts" and not allow them to become a basis for action.

My worry is that patients, once they are in recovery, may have an "Eating Disorder thought," conclude that they are relapsing...and, consequently, actually engage in "Eating Disorder behavior" leading to relapse. A self-fulfilling prophecy of sorts. 

Instead, I'd like to reassure them: relapse is best gauged by action, not thought. Everyone has distorted thoughts of one kind or another. What matters is what you DO with your thoughts - how you choose to act. Keep doing what you need to do to be healthy (follow your meal plan, use your supports, avoid purging, limit exercise, etc), and let your thoughts take care of themselves. They may come, but they will also go. Keep the faith, and keep up the fight.

Two Approaches to Anxiety

When it comes to anxiety disorders, particularly panic and phobias, cognitive-behavioral therapy is well-established as the treatment of choice. More specifically, research evidence strongly supports the value of exposure to feared stimuli in decreasing or eliminating anxiety. 

The general idea is that experiencing the stimuli without (1) a feared outcome occurring, and/or (2) responding fearfully through fight/flight or safety behaviors diminishes the cognitive/neurological link between the stimuli and danger. Over time, the fear progressively decreases until it is minimal or even eliminated.

The problem with this scenario is that it requires the client to actually feel all of their fear and anxiety...and they have probably come to therapy hoping not to feel these feelings! It requires significant courage, trust in the therapist, and belief that the end result will be worth the discomfort. It also requires that the costs of living with the anxiety outweigh the discomfort of treatment.

However, given that these conditions are met, and the client agrees to exposure, the therapist has to decide between two competing protocols:

1) Flooding 

In flooding, the client is exposed to the object of intense fear, while preventing avoidance or other safety behaviors (hence the technical name, Exposure and Response Prevention), until the fear subsides. Since a discrete episode of anxiety is time-limited, the fear does in fact dissipate over time, which in turn provides new experience as a foundation for cognitive and behavioral change. 

2) Systematic Desensitization

While flooding dives right in with exposure to intensely feared stimuli, systematic desensitization eases clients in more gradually. Therapist and client work together to create a hierarchy (gradated list) of anxiety-provoking stimuli. Then, treatment starts with exposure to something that produces mild anxiety. Once the stimuli no longer produces anxiety, treatment progresses one step up the hierarchy to something slightly more fear-producing.

Flooding produces more dramatic results in a shorter period of time, but is also more distressing than systematic desensitization. In contrast, systematic desensitization takes much longer to get to the source of anxiety that is causing the client the most distress. However, it also gives the client the opportunity to gain confidence and mastery as they overcome less intense fears, and demonstrates that the approach is effective before asking them to confront more intense fears. 

Given these relative strengths and weaknesses, which do you prefer? Are there situations in which one is preferable to the other? How do your clients respond?

Pleasurable Activities

When we talk about relapse prevention, and overall quality of life, I encourage clients to schedule time each day to do things they enjoy. They often stare at me blankly, in response. Many of them can't actually identify anything they enjoy, and others feel like there are too many more important things or responsibilities they have to meet to "waste time" having fun.

I make sure to tell them that it is not a waste of time. In fact, research supports the value of spending even a brief period of time on positive or enjoyable activities each day in changing brain chemistry and (therefore) mood. Spending 10 minutes "playing" makes the time you spend "working" more productive and less overwhelming. It is well worth it!

For people who don't know what they enjoy, I provide the following list, and encourage them to highlight the things they think they might like, or are curious about. People might also be able to identify things they used to enjoy, or things they heard about that interested them but they haven't tried. Here is the list I've compiled. If you notice anything missing, add on using the comments!

• Shopping
• Event planning and organizing
• Wedding planning
• Camping
• Swimming
• Party planning
• Dog training
• Fitness and aerobic exercise sessions
• Horse riding
• Traveling
• Cooking
• Knitting
• Jewelry making
• Making gift baskets
• Crochet
• Family tree
• Geocaching
• Puzzles (Sudoku, crossword, jigsaw, etc)
• Reiki
• Different types of painting such as:
• Oil painting
• Glass painting
• Acrylic painting
• Faux painting
• Watercolor painting
• Paint by numbers
• Quilting
• Writing
• Interior decorating and designing
• Listening to new music
• Learning to play an instrument
• Home decorating
• Creating wall art and wall hangings
• Candle making
• Learning foreign languages
• Visiting beauty salons, clinics, and indulging in the following:
• Spas
• Manicures
• Massages
• Steam saunas
• Tanning
• Acupressure
• Acupuncture
• New hair accessories, and haircut styles and ideas
• Designer handbags and jewelry
• Embroidery
• Crystal healing
• Learning tarot card reading, astrology, or handwriting analysis
• Buying antiques and unique collectibles
• Going to garage sales and flea markets
• Becoming a collector of anything
• Handcrafted jewelry
• Setting up a fish tank with aquarium fish
• Beading
• Spiritual healing
• Aromatherapy
• Cake decorating
• Handicrafts
• Cosmetics
• Flower arrangements
• Origami
• Sewing
• Indoor gardening and other similar activities such as:
• Growing roses
• Managing flower gardens
• Growing bonsai trees
• Caring for houseplants
• Growing vegetable gardens
• Building a rock garden
• Organic gardening and composting
• Yoga
• Coaching
• Feng shui
• Pottery
• Pursuing mosaic, stained glass and pastel art
• Home based business opportunities
• Start a blog
• Scrapbooking
• Wood carving/crafts
• Learn about investments
• Make a gift for someone
• Watch sports, join a fantasy league
• Fishing
• Watch children or animals play
• Go to plays, concerts, or museums
• Refinish old furniture
• Visit national parks
• Photography
• Kite flying
• Identify a topic of interest and learn more about it
• Play pool or darts
• Sit at a sidewalk café
• Browse used book stores, or consignment stores

The Cognitive Model

Cognitive Therapy is based on the so-called cognitive model - a theory that conceptualizes emotions and behaviors as resulting from the content of people's thoughts. Instead of seeing situations as triggers for emotions and behaviors, thoughts are seen as the mediator between situation and reaction.

All of us have thoughts rattling around in our heads all of the time. After all, the brain's job is to think. We are not aware of all of these thoughts - if we were, we would never be able to focus on anything! And, not all of our thoughts are "true" or "accurate" - that is not a natural property of the human brain.

When we experience... well, anything, really...it triggers a series of "automatic thoughts" - whatever words or images begin running through our minds. We may be aware of these thoughts...but we may not. According to the cognitive model, these thoughts produce our emotions and behaviors (of which we are more likely to be aware).

A starting point of CBT is often teaching clients to identify automatic thoughts. In fact, some symptom improvement can happen very quickly when a client starts to identify automatic thoughts. This happens because identifying the thoughts begins to unearth cogntive distortions. By recognizing distortions and ceasing to accept distorted thoughts as Truth, they lose some of its power over emotions and actions.

The cognitive model does not stop there, however. It asks: where are these automatic, distressing and/or distorted thoughts coming from? The answer provided by the cognitive model is that automatic thoughts arise from another category of thoughts: beliefs.

We all develop beliefs about ourselves, other people, and the world we live in, beginning in early childhood. Some of these beliefs are so fundamental to how we view...everything...that we see them as absolute truths. The cognitive model calls these "core beliefs." We may not be consciously aware of our core beliefs - they are kind of like the water fish swim in. However, they have a significant impact (like water does for fish): situations can activate core beliefs, which then shape our perception and interpretation of the situation. In fact, we tend to filter incoming information to accept information that fits the core belief, while discounting anything that contradicts our belief.

The way that core beliefs influence our perception, interpretation, and response to a situation is through what is called "intermediate beliefs." This category includes our attitudes, assumptions, and rules. Attitudes are evaluative statements ("It would be terrible if..."), assumptions tend to be "if...then..." statements, and rules are "shoulds" (or musts, or oughts). These intermediate beliefs arise from core beliefs, either as logical extensions thereof, or as attempts to cope with a painful core belief (often that one is inadequate and/or unloveable): I am inadequate so I need to work harder than everyone else. I am unloveable, so I should expect rejection. Etc.

If CBT begins with automatic thoughts, it's only a matter of time before beliefs start popping up. Themes may start to appear among automatic thoughts that cause distress. Some thoughts may even be direct expressions of a belief. These beliefs then become the substance of therapy - evaluating their usefulness (pros/cons), examining evidence for and against, and considering possible modification or replacement of unhelpful beliefs. Of course, this is not nearly as easy as it sounds, but a full description of the process is beyond the scope of this post.

So, this, then, is the cognitive model: early life experiences shape core beliefs, which give rise to intermediate beliefs. A given situation activates relevant beliefs, resulting in automatic thoughts, which in turn shape emotions and behaviors. Changing automatic thoughts can lessen distressing emotions and maladaptive behaviors, while changing core beliefs can prevent the automatic thoughts in the first place.

Do you buy into the cognitive model? How do you use it, or why do you not? What seems useful and less useful about it?

13 Common Cognitive Distortions

A motto I live by: Don't believe everything you think.

I think this principle is crucial to overall happiness, simply because the human brain has a tendency to make predictable errors which, left unchecked, contribute to distress. We call these errors cognitive distortions. They result from mental short-cuts that evolved to help us manage the volume of incoming information, and therefore allow us to function more effectively.

Except when they don't. It's unfortunate, but true, that these short-cuts seem to favor negative thoughts - perhaps as a way to ensure survival by preparing us for the worst possibilities. However, while we usually do survive, these negative thoughts can dampen our mood, and interfere with effective action.

When this happens, notice what you're thinking, and be on the lookout for these common distortions:

1) Assuming: 

Assuming the worst without evidence, and without testing the assumption. We tend to act on our assumptions, and limit our opportunities as a result. More balanced thinking considers other (more positive) explanations.

Examples: “I know I’m going to fail, so I’m not even going to try.” 

“She didn’t call me back. She must not want to be friends.”

2) Shoulds: 

Demands we make of ourselves and/or others. We may think should statements motivate us, but really they just make us feel inadequate when we are (predictably) imperfect about following them. More balanced thinking replaces “should” with things like “could,” “it would be nice if” or “I want to.”

Examples: “I should be thinner.” “I should exercise.”
“I should be the perfect student or employee.”

3) Fairy-Tale Fantasy: 

Expecting life to live up to an ideal. Statements like “It’s not fair!” or “Why did that have to happen?” are really saying that the world should be different. In reality, bad and unfair things happen to good people – sometimes randomly, sometimes because of others, and sometimes because of our own choices. To expect the world to be different is to invite disappointment and unhappiness. Replacing “should” with “it would be nice if” can work here, too…along with acceptance of “life on life’s terms.”

Examples: “It shouldn’t be so hard to meet people.” “People should be more considerate.”

4) All or Nothing Thinking (Black or White Thinking): 

Thinking about things in extremes, using absolute categories: If it’s not black, it must be white.” This kind of thinking fails to recognize all the possibilities in between black and white (the grey area).

Examples: “If I’m not the best, I’m a failure.” “If I’m not the prettiest, I must be ugly.”

5) Overgeneralizing: 

Deciding that a negative experience is a never-ending pattern that describes your life completely. Overgeneralizing makes you feel worse, and is inaccurate because it overlooks all the times things have been and/or will be different/better.

Examples: “Nobody likes me.” “I ruin everything.” “I always end up relapsing eventually.”

6) Labeling: 

Calling yourself (or others) a name, as if that word describes the person completely. Labels oversimplify people (who are complex, and have strengths and limitations), and also overgeneralize (e.g., describing the whole person based on a single behavior). If you have to use labels, label behavior, not people. (e.g., “that was a silly thing to do,” rather than “you’re silly”).

Examples: “I’m such a loser.” “I’m disgusting.” “What a jerk.”

7) Dwelling on the Negative: 

Focusing on the negative aspects of a situation, while ignoring the positive aspects. When you do this, soon the whole situation looks negative. Instead, actively look for positive or neutral things that you might be missing

Examples: “Someone criticized me, so the whole day is ruined.”

“How can I enjoy myself when my children have problems?”

8) Rejecting the Positive: 

While dwelling on the negative just overlooks positives, this distortion actively rejects and negates positives. You come up with reasons why the positive things don’t matter.

Examples: “I just got lucky – it has nothing to do with my abilities”
“Anyone could have done that – it was nothing.”

9) Unfavorable Comparisons: 

This is like having a special magnifying glass that magnifies some things (your negatives, other people’s positives) and shrinks others (your positives, other people’s negatives). You compare your out-takes with someone else’s highlight reel. Instead, try recognizing everyone (even yourself) as having unique strengths and weaknesses. If you have to compare, try to comparing evenly – include both favorable and unfavorable comparisons.

Examples: “She’s thinner, so she’s prettier; who cares if I have nicer hair?”
“She is more successful because she runs more; who cares if she’s unemployed?”

10) Catastrophizing: 

This involves both assuming the worst case scenario, and telling yourself you can’t stand/handle/cope with it. However, the reality is that, while the situation may be uncomfortable and challenging, we really can stand anything that doesn’t actually kill us. Stop and ask yourself how likely it is that the worst will really happen, whether you are likely to survive it, and if so, come up with some strategies to cope.

Examples: “I can’t tolerate having an urge without acting on it.”
“I couldn’t stand it if he broke up with me.”

11) Personalizing: 

Seeing yourself as personally responsible for negative events that are beyond your control, or more responsible than you really are for problems to which youmay have contributed. Every event becomes a reflection of worth (or lack thereof). Instead, distinguish between those things you can control, those you can influence but not control (e.g., others’ behavior), and those over which you have no influence or control. Also look for other, external influences (e.g., maybe she hasn’t called because she has a lot going on, not because she is angry with me”).

Examples: “It’s my fault my relationship failed.” “She hasn’t called; she’s angry with me?”

12) Blaming: 

The opposite of personalizing, blaming puts all the responsibility for your difficulties on something outside yourself. The problem with blaming is that it leads us to think about ourselves as victims who are powerless to cope. Balanced thinking acknowledges both outside influences and personal responsibility.

Examples: “You made me relapse.” “Having a bad childhood ruined my life.”

13) Making Feelings Facts: 

This distortion involves taking your feelings as proof of the way things really are. Since feelings result from thoughts, and thoughts are often distorted, feelings also do not reflect objective reality. Stop and check the thoughts behind the feelings to see if you may be seeing things in a distorted way. Changing thoughts changes feelings.

Examples: “I feel ashamed. I must have done something wrong.” “I feel worthless, I must be worthless.” “I feel fat, I must be fat.”

Based on: Schiraldi, G. R. (2001). The Self-Esteem Workbook.

Escaping the Waiting Place

In his guide to life, "Oh, The Places You'll Go," the sage Dr. Seuss warns readers about:

"a most useless place. The Waiting Place...for people just waiting. Waiting for a train to go, or a bus to come, or a plane to go, or the mail to come, or the rain to go, or the phone to ring, or the snow to snow, or waiting around for a Yes or a No, or waiting for their hair to grow. Everyone is just waiting. Waiting for the fish to bite, or waiting for wind to fly a kite, or waiting around for Friday night, or waiting, perhaps, for their Uncle Jake, or a pot to boil, or a Better Break,
or a string of pearls, or a pair of pants, or a wig with curls, or Another Chance. Everyone is just waiting."

 

Most of us can probably relate. I think most people find themselves, at various points in our lives, feel like we have to put everything else on hold while we're waiting for...whatever it is we're waiting for. We wait to grow up, to go to college, to finish college, to get the perfect job, to buy the perfect house, to find a spouse, to have a family, for our kids to walk, start school, finish school...etc. We can spend most of our lives waiting for some future point to really live!

The same pattern can play out in therapy. All too often, clients say they "aren't ready" to change their behavior, or talk about/work on something sensitive, or take whatever risk they need to take to reach their life goals. They want to wait - until it stops hurting, or they stop having distorted thoughts, or completely resolve the last little bit of ambivalence, or stop feeling depressed (angry, anxious, whatever), or "get over" their grief, or forgive someone, etc., etc., etc.

Dr. Seuss does not happen to offer any sage advice on escaping the Waiting Place (he writes only: "Somehow you'll escape all that waiting and staying. You'll find the bright places where Boom Bands are playing"). However, barring a boom band showing up in our offices, therapists are challenged to find creative ways to help our clients break out of their "waiting."

I think it starts with psychoeducation. At its heart, waiting is the result of inaccurate or distorted thoughts or beliefs about the nature of feelings, thoughts, and actions. For example, people often operate on the assumption that feelings are an accurate basis for, or inevitable determinant of behavior. Based on this assumption, people who are depressed often say that they'll get up, shower, get dressed, socialize, etc, once they "feel better." However, research suggests that people begin to "feel better" once they start getting up, showering, socializing, etc. (an approach called Behavioral Activation). Identifying, and providing education to counter, the inaccurate assumptions impeding the client from taking necessary action is an important first step.

Even with this foundation, clients may still be stuck in the Waiting Place. Here's the hang up: we judge the veracity of new information based on how it fits with our experience. Without taking action, clients have no new information to test out the accuracy of what we want them to believe. But, they don't want to take action until they believe the new information. We have a few options in this sort of stalemate. We can continue trying to "talk them into" believing the new information. We can facilitate "vicarious learning" by pointing to others whose experiences provide support for the new information. Or, we can encourage clients to test it themselves in a small experiment. Instead of committing to sustained effort or change, they can just try it for a limited time or in a limited frequency, and self-monitor for any changes in how they feel (the experiment should be long enough to provide accurate information, however!). Finally, we can reach for any past experiences the client may have had that provide supporting evidence.

What other strategies do you have for helping clients (or yourself) escape the Waiting Place?

"Underlying Issues"

When people seek therapy to address a problem behavior, whatever that behavior may be (e.g., addictions, eating disorders, impulsive or compulsive behavior), they also usually bring up the issue of "underlying issues" early in treatment.

Some want to focus on behavior change, and bring up "underlying issues" only to request that they not become the focus of treatment, either because "there aren't any," or they're irrelevant to the problem at hand. They are highly skeptical of the stereotype of therapy delving into one's childhood, and assume that changing behavior will be sufficient. Others take the opposite stance, expressing frustration with a focus on behavior change, and asserting that the problem is not the behavior itself, but the "underlying issues" that have caused it. They assume that behavior change will happen automatically if underlying issues are resolved, but intentional behavior change will be transient if these issues are not addressed.

While such requests immediate arouse my curiosity/suspicion about what the person may be avoiding or defending against, or what past experiences are informing their request, I also understand the dilemma. After all, therapeutic approaches have been similarly divided on the most appropriate and efficacious focus for treatment. Psychodynamic and analytical approaches take the latter stance, that behaviors are simply markers of underlying issues, which should be the focus of treatment, with the assumption that resolving underlying issues will also resolve any problematic behaviors. Consequently, interventions focus on uncovering whatever the "underlying issues" may be (for example, via free association, transference/countertransference, etc), and resolving them through analysis, interpretation, and the resulting development of "insight." 

Behaviorism developed in reaction to psychoanalysis, almost as an antithesis. It is no surprise, therefore, that its descendants (e.g., Cognitive Behavioral Therapy) have a reputation for "no-nonsense," short-term interventions targeting behavior change, either by focusing on the behavior itself, or the thought process in which it is embedded. The assumption is that changing behavior, either on its own, or by changing thinking, is sufficient to achieve symptom relief (and avoids the lengthy and therefore costly therapy required to resolve those pesky "underlying issues").

However, most therapists I know (including myself) subscribe to a both/and, rather than either/or, approach - in other words, many of us espouse an approach that integrates the faster symptom-relief of approaches such as CBT, with the longer-term but longer-lasting resolution that comes from addressing "underlying issues." We've probably adopted this stance because we've seen incomplete or transient improvement as a result of a behavioral focus, but also witnessed clients' frustration or discouragement at the slow rate of behavior change when the focus is exclusively on underlying issues.

Because I subscribed to this kind of integrate stance, I was intrigued by the following defense of CBT as a potential access point to "underlying issues."

CBT's focus on symptoms is not meant to be a superficial intervention that has no implications for what lies beneath. Instead, by beginning with the symptoms that are present and accessible, the therapy process has access to what is fundamental and significant in determining the emotional and psychological health of the individual and thereby has the potential to facilitate meaningful and profound change. If CBT were merely a superficial intervention, it would be like weeding a garden by snipping off the top leaves. Instead, CBT interventions begin with the top leaves and follow the organic connections until the roots of the problem have been identified and weeded out. (Pike, Devlin & Loeb, 2004)

What do you think about this question of behavior change vs. underlying issues? How do different approaches you've learned navigate the question? What does it really take to "facilitate meaningful and profound change?"

The Sky is Falling!

Do you remember the story of Chicken Little? (You probably heard it as a child, but if you don't remember that, you might remember the...adapted version...made into an animated movie in 2005). It begins when an acorn drops on an unsuspecting Chicken Little as he's walking through the woods, hitting him on the head. Not seeing the acorn, Chicken Little concludes that a chunk of the sky has fallen on him. He panics, and runs off to alert the King - and everyone else he meets! - that "the sky is falling!"

It is easy for even children to recognize how silly Chicken Little's conclusion is - the sky isn't made up of something hard, and chunks can't fall out of it. However, at some point or other, most of us have "sky is falling" moments. You know what I mean: We jump to conclusions based on very little evidence. We catastrophize, imagining all the possible worst-case scenarios. We work ourselves - and sometimes the people around us - up into a panic, completely unnecessarily. We can all relate to Chicken Little.

So, why do we do this? Why do these thoughts, which CBT labels cognitive distortions, seem so ubiquitous? I think of it as something brains do, trying to be helpful. The brain's job is to think, after all, and it's pretty darn good at problem solving, so it figures that we'll be ok as long as it can identify and plan for all possible outcomes. And, if it can plan for the worse possible outcomes, better outcomes should be a piece of cake, right?

Unfortunately, the brain's strategy doesn't actually help that much - in part, because the brain is very creative and keeps coming up with additional strategies or details, and in part because the process of thinking all of these things tends to spike our anxiety.

There are a few different strategies for these "sky is falling" moments (depending on the person and situation). 

1) Worry control - as the brain spits out all of its possible scenarios, you can try to make them less anxiety-provoking by asking two questions: how likely is this, really? and could I handle it? Usually the answer to the first one is low, and the second one is some version of yes (or sort of, probably, etc). Therefore, even if the thoughts continue, the panic subsides.

2) Reframe - classic CBT, this involves catching the thoughts and replacing them with more balanced thoughts. (While this may sound similar to worry control, the difference is that worry control allows the catastrophizing thoughts to continue, it just frames the catastrophe as unlikely and/or manageable; reframing tries to stop the distorted thoughts altogether). 

3) Relaxation - instead of approaching it through the thoughts themselves, you can also try to approach it through the body. Just as thoughts can produce physical anxiety, physical relaxation can restore balanced thinking. Progressive muscle relaxation may be the easiest strategy, since it focuses on the body rather than requiring more mental concentration, such as meditation or mindfulness does. 

Do you find one of these strategies more (or less) helpful than the others? Are there other strategies you use to combat catastrophizing?

Are You Being or Becoming?

In the book Mindset: The New Psychology of Success, Carol Dweck suggests that how we think about our capabilities plays a significant role in how far our abilities stretch. She refers to these ways of thinking as "mindsets."

We're often taught a particular mindset early in life - what Dweck calls the "fixed mindset." Actually, what is "fixed" isn't the mindset. Instead, the fixed mindset involves the belief that our capacities - tendencies, traits, talents - are "fixed." In other words, our strengths and weaknesses are predetermined from birth, and life is about "being" what we already are. Success, therefore, depends on learning to play to our strengths, and compensate for our weaknesses.

As a result, many of us try really hard (without seeming to) to prove that we "have it," whatever "it" is - intelligence, creativity, athleticism, musicality, and various other types of acumen. Through this lens, success involves proving yourself (or your innate ability, anyway), and failure results from a lack of innate ability. Even having to work at something can be taken as a sign that you don't have enough talent. The outcome, rather than the process is what matters, and that outcome has significant bearing on your perception of worth and identity (are you a "success" or a "failure"?).

Fortunately for all of us imperfect folk (in other words, all of us), there is an alternative - what Dweck calls the "growth mindset." The growth mindset assumes that we can always learn and grow from where we are now, without fixed barriers to what we can "be." If we're willing to work at it, we will continue to evolve in a process of "becoming."

Success is therefore redefined - we succeed when we stretch and grow, working hard creates our talents and abilities, and the only failure is when we stop trying to grow. When we are unable to do something (what the fixed mindset sees as failure), it's about "doing" rather than "being" - in other words, it's not a threat to our identity. What matters is what we are able to learn from the experience - process is more important than outcome.

As you might imagine, this growth mindset has a lot of potential to eliminate some of the barriers we create for ourselves in a fixed mindset. It protects our sense of self, while motivating us to keep trying to grow.

So, are you being or becoming?