Chapter 8: Cognitive Work/ Identifying targets

Question 1

good way to access the clients ability to engage in metacognition

Answer 1

• wait for a situation to emerge early in therapy in which you realise that the clients thoughts have affected how he or she feels and reacts
• you can use this example and describe a basic version of the cognitive-behavioural model as you describe the situation-thought-response chain
• establish that there is a linkage between thoughts in different situations and responses to those situations
• encourage client to pay attention to similar response patterns

Question 2

the client who struggles to identify events or triggers

Answer 2

• situation needs to be clear and detailed
• use role-play if it is an interpersonal situation
• if situation is not a single, static moment, but evolves over time: break set of events down into discrete moments
• mood shifts during therapy sessions provide opportunities to help client focus on internal experiences, and to improve emotional self-expression

Question 3

the client who has difficulty identifying emotions

Answer 3

• clients who come from emotionally impoverished backgrounds
• discouraged from talking about feelings in the past
• simply not very psychologically minded
• therapy language not their first language
• should be discouraged from using vague terms, use words that are more descriptive and specific
• through various combinations of types of experiences, degrees or intensity labels, and specific terms, clients can develop more complex, nuanced, and idiographic ways to express themselves

Question 4

the client who is confused about the nature of feelings

Answer 4

• some clients use terms that we associate with emotions or action impulses to describe their thoughts (e.g., I thought sad thoughts, I felt I should leave)
• help client to differentiate more accurately among feelings, thoughts and behaviours

Question 5

the client who struggles to identify thoughts

Answer 5

• ask a series of questions to help client pay attention to their thought processes
• e.g.,
• what were you thinking in that situation?
• Does this situation remind you of other, similar situations, in which you knew what you were thinking?
• Did you have any particular images in your mind?
• What would someone else think in that type of situation?

Question 6

the client who struggles to identify thoughts: 3 comments about the process of inquiry related to automatic thoughts

Answer 6

1. provide a context for further inquiry: “This seems pretty important to you…”: help the client to tolerate difficult questions
2. bear in mind that questions ask for speculation, e.g., how do you think someone else might react
3. be tentative and not suggesting (e.g., rather might you have been thinking…? instead of it sounds like you were thinking…, right?)

Question 7

the client who poses thoughts stated as questions

Answer 7

• e.g., Will I be accepted? What if I fail?
• most clients do not just raise the question but also answer the question in a negative fashion
• why questions: not to engage in philosophical discussion, rather expression of a part of their belief system

Question 8

the client who confuses thoughts with beliefs, schemas or assumptions

Answer 8

e. g. I could not do my homework because I felt unable to start, which once again proves what a failure I am.
- early in therapy: only focus on first part of the response, automatic thoughts
- global sense of being a failure should be noted but not addressed early in therapy

Question 9

methods for collecting negative thoughts

Answer 9

1. (modified) daily dysfunctional thoughts record
2. frequency record
3. remembering
   - 1-2 sessions focused only on thought recording, without any attempt to intervene, and then pick one or two easy targets for intervention to see how amenable to change these thoughts may be

Question 10

interventions for negative thinking

Answer 10

• several types of negative thoughts that receive the most attention in therapy
  1. negative thoughts that are connected with strong emotional reactions
  2. connected to a strong behavioural response pattern, such as escape or avoidance
  3. consistent with your preliminary case formulation, including the diagnosis and problem list
  4. negatively biased or distorted
  5. repetitive thoughts because these more likely reflect cognitive themes and core beliefs
  6. strong degree of belief associated with them: likely the hardest ones to change
  7. surprising thoughts: worthwhile to pursue this thought for a while, as it may suggest the need to edit your case conceptualisation, and possibly your treatment goals