The PWP intervention Files: Cognitive Restructuring

Information about the Improving Access to Psychological Therapies scheme, the different roles, training courses, professional bodies and the KSF requirements.
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matt.berlin
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The PWP intervention Files: Cognitive Restructuring

Post by matt.berlin » Sun Aug 15, 2010 9:36 pm

Also known as
Challenging / changing unhelpful thoughts

Aims
The aim of cognitive restructuring is to address unhelpful thinking by increasing attention to facts that don’t fit with the unhelpful thought, and then finding an alternative, more helpful or more balanced thought.

‘Thought diaries’ and ‘evidence recording sheets’ are often used to help the client practice this new technique. However, in the longer term once a client has mastered the technique, you can encourage them to use it whenever and wherever they notice an unhelpful thought without the need to write anything down.

The principles
PWPs are trained to work with what CBT calls ‘Negative Automatic Thoughts’ (NATs) - and not with the ‘deeper’ levels of Dysfunctional Assumptions or Core Beliefs. (However, PWPs may find that these do pop up with clients from time to time and if you use the computerised CBT (cCBT) programme Beating the Blues, then this does go down to Core Belief level.)

NATs – or unhelpful thoughts – are thoughts and images that routinely pop into our minds that are connected to negative emotions. They tend to come and go very rapidly but are very convincing all the same. An example of a NAT for someone struggling in a new job might be: “I’ll never be good at this job”.

Cognitive Restructuring works on the idea that: Situation -> Thoughts -> Emotions. To change the emotions and help people feel less depressed or anxious, we help them change the unhelpful thoughts that are contributing to these feelings.

Steps
The intervention is introduced slowly, often over the course of three sessions. This can be done either using single worksheets, more substantial workbooks such as those in Chris Williams’ books, or as part of a cCBT package. As ever with CBT-based interventions, a lot of the work is set as homework tasks to be done between sessions.

Week 1: Identifying thoughts and feelings
Firstly, client is asked to identify the situations or type of situations that the unhelpful thoughts occur. Although the theory goes that Situations lead to Thoughts which lead to Feelings, we identify feelings next, as these are often more accessible to clients than their unhelpful thoughts. Part of the intervention is training people to identify these thoughts more easily.

Secondly, they identify how they feel in these situations, rating the severity of each emotion or mood (perhaps as a percentage: e.g. 0% not upset at all actually -> 100% the most upset I have ever been). It can be helpful to use the words emotions or moods, as many people understand the word feelings to be thoughts as well as emotions. Take care to help the client differentiate between the two!

Thirdly, it is now time to actually identify the thoughts themselves. Again, clients are asked to rate these in terms of how much they believe them (e.g. 0% I don’t really believe this at all, 100% I believe this thought completely). This can sometimes require a bit of help to identify thoughts. Once a number of thoughts have been identified, it is time to find the ‘Hot Thought’ – which is the thought that is linked to the strongest emotion.

Week 2: Evaluating the evidence
The next step is to look for factual evidence for and against this Hot Thought. Here it is important to emphasise that you are looking for facts only – not thoughts or feelings! One way of doing this is by using a court of law analogy, saying that the client is having to be their own judge and jury and can only use evidence that would stand up in court.

It is usually easiest to start with the “evidence for” as this is what people have already been paying attention to. “Evidence against” can sometimes be more difficult and it is important to normalise this experience for clients as it is a new skill they are learning.

Sometimes it can be appropriate to gently challenge clients including something as evidence for their unhelpful thought. After having looked at it again – they may change their minds and see that what they thought supported their way of thinking, doesn’t do so necessarily.

Week 3: Finding an alternative or more balanced thought
The final step is to use the evidence-recording that the client has done as a guide for finding a more helpful or balanced thought. Once they have done this, ask the client to rate their belief in this new thought (as above in Week 1) and to re-rate the emotions identified in the first stage, for how they are now with the new thought. This helps draw attention to how the new thought(s) affect the client’s mood.

A worked (fictitious) example:

Situation:
Giving a solo presentation on cognitive restructuring to colleagues

Moods:
Anxious (75%)
Terrified (50%)
Uneasy (60%)

Thoughts:
I am bad at presenting stuff (70%)
I don’t know what I am talking about (50%)
People will think I am stupid (80%)
I will look nervous (100%)
I want my mummy! (100%) (ok, maybe not this one!)

Hot thought:
People will think I am stupid (80%) – other thoughts were rated higher than this one, but this seems like it is the more important thought

Evidence for:
I was very nervous the last time I presented something
I haven’t read up on cognitive restructuring recently

Evidence against
I use this technique all the time and know it well
My colleagues are intelligent people and understand about anxiety
My colleagues have already told me they think I am smart
I wouldn’t judge another colleague’s intelligence on the basis of one presentation

Revised thought:
If I am nervous or badly prepared, it does not mean that people will think I am stupid, just nervous or badly prepared (85%)

Re-rated moods:
Anxious (35%)
Terrified (5%)
Uneasy (40%)


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Content checked by qualified Clinical Psychologist on DATE
Last modified on 15/08/2010

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