Module 3: Cognitive Restructuring
The third phase of a depression protocol involves using standard cognitive restructuring techniques to identify maladaptive beliefs that can become targets for change.
This phase begins with some psychoeducation on the CBT Iceberg, the automatic nature of thoughts and the differences between the conscious and unconscious systems of the brain. You will then be educated on cognitive distortions and asked to identify examples in your own life. This is facilitated by describing a recent situation that caused you to feel depressed and then identifying a thought to be used to identify distortions.
After this psychoeducation, you will then be introduced to the thought record in session and then asked to begin filling out the first three columns for homework whenever you notice a large decrease in mood. Subsequent sessions involve education on the validity and utility of thoughts and doing homework to ensure you are practicing using these new tools.
- Validity Techniques: Evidence technique, cognitive distortions, cognitive continuum, responsibility pie, best friend technique.
- Utility Techniques: Cost/Benefit Analysis, behavioral experiments, best-friend technique, maladaptive consequences.
If you determine that a belief is valid and not distorted, then a shift towards problem solving can be helpful. Not all beliefs are distorted and sometimes you truly are in non-responsive environments that need to be changed. The specifics of problem solving training are covered in another post.
Over time, the main objective of this phase is to begin to identify themes and patterns in the thought records that you complete in session and for homework. Once these themes are identified then core belief work can begin.
Thought records form the foundation of the new house of thought (and therefore mood) that we are developing. Thought records are like training wheels when learning to ride a new bike. They guide a certain process of thinking that is meant to be internalized and eventually done automatically on one’s own without the need for any paperwork. CBT is learned line upon line and this is the tool to one of the most important lines for clients to know. The Thought record is simply the five factor model rearranged with a few more columns added to help you challenge and reconstruct your beliefs.
When you first fill out a the thought record it can be overwhelming to so you only have to fill out the first few columns at first. You are to use the thought record whenever you notice a shift in mood and you are to record the situation you are in, what emotion you are feeling, what you are doing and finally what you are thinking. After you have written down all of your thoughts you are to identify your “hot thought” or the thought that hurts you the most. If you are struggling to identify the hot thought ask yourself: “If you could get rid of only of these thoughts, which one would it be?” It is important you identify which thought is most harmful because that thought will be the focus of the rest of the thought record.
Here are some pointers for how to fill out each of these columns:
- Situation: Ideally, you want to confine a situation to a 30 minute period in your day. You want to answer the 4 W’s: Who, What, When and Where. The 30 minute period to look at should begin when the client noticed a shift in their mood.
- Mood/Emotion: In this column, you want to list only emotions and sensations and not thoughts or interpretations. Many clients struggle with differentiating between thoughts and emotions. Commonly, clients will say things like “Hurt” or “Alone” which are not emotions but they probably mean “Sad” or “Scared.” You can use emotion lists to help with emotional vocabulary and you can get some psychoeducation on what emotions are, how to recognize them and what their functions are. This thought record provides the basic emotions that you simply need to circle and then rate how strongly you feel these emotions on a SUDS scale (1-10).
- Thoughts: In this column, write down everything that you are thinking, no matter how stupid you might think those thoughts are. It is very important that you are honest here and do not censor yourself. After writing down everything you were thinking you need to identify and write down the thought that is most painful to you (hot thought) so that it can be the focus of analysis and possible change in the following columns.
- Behaviors: In this column simply record what you did or didn’t do in response or reaction to the situation. This will help us identify maladaptive coping responses that may be the target for future change.
After you have practiced filling out the first few columns you can move to the next columns.
- Distortions: In this column, simply identify how your hot thought is distorted using this post as a guide.
- Evidence: In this column, outline evidence for and against your belief. You can use this post as a guide.
- Utility: In this column, determine how useful this belief is and whether it is helping you meet your goals.
- Balanced Belief: Create a new balanced belief that acknowledges the negatives but balances those negatives with positives. A simple formula you can use is: “While x negative thing is true y positive thing is also true.”
Best Friend Technique
The Best Friend Technique is a simple Socratic question designed to help you gain some objectivity and take the perspective of someone else who cares about you. It helps you escape your limited perspective and should induce some self-compassion and empathy. The Best Friend Technique involves some variation of the following question: “If your best friend was in this situation, what would you say to them? If you have a really wise and loving best friend, what would they say to you if you told them your thoughts? What would I/a therapist say?” The thought record provided even gives you a column where you can ask yourself this question and fill in the answer.
To make Coping Cards simply take the balanced beliefs produced through thought records and write them down on a cue card. Next, place those cue cards in areas that are likely to trigger distorted thoughts so that you can be reminded of the new belief you are trying to reinforce. Cue Cards should be read daily so that you can be reminded to practice reinforcing more balanced perspectives.
The Main Goals for Phase 3 include:
- Providing psychoeducation on the CBT Iceberg, automatic thoughts & conscious/unconscious brain system.
- Education on cognitive distortions and identifying them in sample beliefs.
- Introducing the thought record and teaching about validity and utility techniques.
- Homework: Collecting thought records to identify themes and core beliefs to be challenged.