Module 10: Challenging Maladaptive Thoughts and Beliefs

Objectives

• To learn techniques for addressing dysfunctional thoughts and beliefs

• To understand and manage potential difficulties using thought records

What are the techniques for challenging maladaptive thought, and why are these techniques important for
Brief CBT?

Several techniques can be used to challenge dysfunctional thoughts or beliefs. Most are used in conjunction with a
thought record. Challenging thoughts and beliefs in a collaborative, Socratic way allows patients to use their own
statements to counter dysfunctional thinking. Generating counter-statements based on the data patients bring to
session increases the believability of the thoughts/beliefs and, thus, the effectiveness of the counter
thoughts/beliefs.

When? (Indications/Contraindications)

Typically dysfunctional automatic thoughts are the first targets in the cognitive component of CBT. Following the
introduction of the cognitive model (see Module 5: Orienting patient to Brief CBT), and skills for identifying automatic
hot thoughts and their accompanying emotions (see Module 9: Identifying Maladaptive Thoughts and Beliefs),
techniques for challenging hot thoughts are introduced. These techniques should immediately follow the session on
identifying hot thoughts, to build continuity and familiarity with the skill set and instill hope of change after identifying
problematic thinking patterns. Although intermediate and core beliefs will be challenged in advanced stages of
therapy, the techniques are similar for challenging thoughts. Many techniques below can be used interchangeably
for challenging thoughts or beliefs. Brief CBT session time is best used for modifying thoughts or beliefs that are
tightly held and strongly believed.

How? (Instructions/Handouts)

Socratic questioning is a therapist stance for questioning maladaptive thoughts and beliefs.
This process involves asking a series of open-ended, brief questions that guide the patient to discover his/her
idiosyncratic thoughts, feelings, or behaviors associated with a particular situation. Socratic questioning is
nonjudgmental but is based on the therapist’s insight that the original premise of a thought or belief may be untrue;
therefore, the questions are designed to expose the dysfunctional thought or belief so that it may be challenged.

The Dysfunctional Thought Record (DTR) is the staple of cognitive work in Brief CBT. The first three columns (see
Thought Record handout on p. 55) are used for identifying troubling situations and the accompanying emotions and
dysfunctional thoughts. These three columns are used in conjunction with Module 8, in that when the situation →
thought → feeling triangle is unfolded, it forms the first three columns of a DTR (see figure).

A seven-column thought record is used to challenge dysfunctional thoughts and beliefs. Instructions for
completing columns 4-7 are described in detail below.

Once a hot thought and its accompanying emotion have been identified and rated, the hot thought is questioned
to generate evidence for and against it. Building evidence may be introduced in the following way:

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Example: We have identified a thought that is very powerful for you. You rated this thought as 90 out of
100 for sadness. Before spending a lot of time and energy on this thought, I want to know whether or
not it is true. Often when people are depressed or anxious, they take thoughts like this at face value,
without first asking whether it is true. Accepting thoughts like this as true would certainly lead to the
symptoms you’ve been struggling with. If I thought, “I am worthless and can’t do anything right,” I
wouldn’t want to get out of bed in the morning either, and I would probably feel pretty hopeless and sad.
When we test a thought like this, we are going to generate evidence for and against the thought. It is as
though the thought were on trial, and you were a lawyer for the case. Remember, you have to be able
to prove the evidence you are generating. So, now let’s see how your thought stands up….

Developing Balanced Thinking

These instructions might be useful to help patients develop balanced thinking:

1. Help the patient question automatic thoughts by asking

• What evidence is there that this thought is true?

• What evidence is there that this thought is not true?
• What would I tell someone I loved if they were in this situation and had these thoughts?
• If my automatic thought is true, what is the worst that could happen?
• If my automatic thought is true, what is the best thing that could happen?

2. Once evidence has been generated, combine it to form a more balanced thought. This thought will likely be much
longer and more nuanced than the original hot thought.

Example: Taking all this information (from columns 4-5) into consideration, what is a more balanced thought
that more accurately reflects the facts?

You might want to ask the following questions:

• Taking the information into account, is there an alternative way of thinking about the situation?
• Can someone I trust understand this situation in a different way?

3. Rate the believability of the alternative thought between 0-100). If the thought is not more than 50 believable,
more work is needed to identify an alternative thought. Go back to the evidence and keep working.

4. Once a believable alternative thought is generated, re-rate the mood associated with the hot thought (0-100)
after reading the new thought. Reducing a thought/belief to a rating of 0 is not a realistic goal. Instead, a reduction
of 30-50 often provides relief. Often patients will generate new emotions from the alternative thought. However, it
is most important first to re-rate the old mood before generating new emotions.

The same strategy of generating an alternative thought for a dysfunctional thought is used when challenging a
core belief. Once the belief is identified, the evidence is weighed and a new more balanced belief is generated.

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Summary: Completing DTRs

 Identify situation and corresponding thoughts and feelings.

 Identify cognitive distortions in thoughts (e.g., all or none thinking).

 Use Socratic questioning to identify hot thought.

 Elicit and rate emotions associated with hot thought.

 Rate believability of hot thought.

 Generate evidence for and against hot thought.

 Generate alternative thought from evidence.

 Rate believability of alternative thought.

 Re-rate emotion of hot thought that is elicited by alternative thought.

Troubleshooting Thought/Belief Modification

Some patients can see the benefits of doing a thought record immediately, but others might need to be motivated
to be engaged. It is useful to use positive reinforcement to praise the effort of completing a DTR, point out the
sections completed correctly, and review skills for the sections completed incompletely or inaccurately. If a DTR is
assigned for homework, it must always be reviewed during the subsequent session. Taking session time to review
the DTR emphasizes its importance to the patient.

Introducing the DTR as an “experiment” helps alleviate any performance anxiety the patient may have about
completing it and may generate interest (“Give the DTR a try this week, and we’ll see how it works for you. Let me
know next session how the experience to complete it was. That will help us decide whether or not this is a useful
tool for you.”)

Occasionally, a patient will show disinterest in doing the DTR or get tired of it after a while.
For instances like this, there are other ways you can suggest that the patient can continue to attempt the DTR:

• If a patient complains of never having time to do a DTR when certain situations occur, suggest that the
patient carry a blank DTR in his/her wallet or purse.

• If a patient has done the DTR for awhile and is becoming disinterested, suggest doing a “mental” DTR,
since he/she is familiar with the process.

• Suggest reading old DTRs that have similar situations and automatic thoughts of their own.

• The patient can verbally dictate a DTR to someone, and have that person write it down.

There will not always be an immediate change to a patient’s mood after a thought record is completed. It might be
necessary to assess why there is no change. It could be attributed to the patient’s deeply rooted belief in the
automatic thought, to an unchanged underlying core belief, or to additional automatic thoughts that have not been
evaluated. It is necessary to ask: Why was there no mood change after completion of the Thought Record? These
other questions will also be helpful.

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• Have I described the situation in enough detail?

• Did I identify and rate the right moods?

• Is the thought I am testing an automatic thought?

• Do I believe a dysfunctional core belief is driving this thought?

• Did I list multiple thoughts? Do I need more information for each individual thought?

• Is there a stronger automatic thought that I have not put in my Thought Record?

• Do I believe the alternative thought? What other alternative thoughts are available?

If thought/belief testing is ineffective in reducing negative mood, you can also explore the advantages and
disadvantages of maintaining a thought/belief. As we know, there are many disadvantages to negative beliefs we
have, but there are also advantages. The patient’s perceptions of the advantages may be obstructing the change
process. Understanding the function of the thought/belief for the patient may be useful in clarifying why certain
thoughts/beliefs are resistant to modification. The therapist should evaluate both the advantages and
disadvantages of a patient’s assumptions and beliefs, but in doing so work to diminish the advantages and
highlight the disadvantages.

Often, when working to modify thoughts and beliefs, the patient may find evidence that supports the negative
belief instead of evidence that contradicts it. If there is a good amount of evidence to support that negative core
belief, then problem solving, rather then thought testing, is an appropriate strategy (see Module 12).

Seven Tips for Effective DTRs

1. You must have mastered the use of DTR before introducing it to patients.

2. Reinforce and make sure that the patient believes in the cognitive model being used.

3. Teach the DTR in two sections: (1) The first three columns; Situation, Automatic thought(s), and
Emotion(s), and (2) the last four columns; Evidence for and against thought, Alternative response,
and New rating of emotion.

4. Use the patient’s exact words when recording thoughts and feelings. Working with thoughts verbatim
preserves the emotions or personal meaning for each thought.

5. The patient should be able to adequately complete the first three columns of the DTR before learning
about the last four columns.

6. Completing a DTR is a skill and, like other Brief CBT skills, requires practice. Success depends on
the patient’s understanding of the steps. Encourage the patient to take time with the skill and work
through any frustration.

7. If the patient is not collaborative in completing the DTR in session or does not complete DTR
homework, it is possible that he or she might have automatic thoughts about this type of exercise.
Ask the patient to create a thought record of the DTR experience.

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Example Homework Assignments

1. List the advantages and disadvantages of keeping a Thought Record.

2. Use an old Thought Record and analyze it using the Automatic Thought Questions we have discussed.
3. Complete the first three columns of a thought record for homework, and complete columns 4-7 with you in
session.

Supplemental Readings

Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press; Chapter 9.
Greenberg, D. & Padesky, C.A. (1995). Mind over mood: Change the way you feel by changing the way
you think. New York: Guilford Press; Chapters 5, 6, & 7.

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THOUGHT RECORD

(1) Situation (2) Automatic (3) Emotion(s) & (4) Evidence to (5) Evidence That (6) Alternative (7) Rate
Thought(s) Mood Support Thought Doesn't Support Thought Mood Now
Thought

Out of breath I’m too old to play Defeated My family has to I can still babysit Because of my Hopeless (10)
when I played in with her. look in on me my grandkids. COPD and
the park with my more because I am Worthless (5)
granddaughter I can’t do what I Sad often than they I contribute to my getting older, I
used to do. used to. family in new have more
ways, such as physical
I can’t be her Sad offering advice limitations than
caregiver. and support. I used to, and I
do need my
I have nothing to Disappointed I still live family’s help
offer my family Hopeless independently. from time to
any more. time, but I am
I am able to do able to offer
I am a burden to Hopeless many things them many
my family. Worthless physically, though valuable
I do have more things and
I am no good to Hopeless (80) limitations than I contribute to
my family. Worthless (90) used to. my grandkids’
lives.(80)

What thought(s)
went through What emotion(s) What has What has
What actually your mind? did you feel at happened happened to
happened? How much did the time? Rate to make you prove the What is another
Where? What? you believe it? how intense they believe the thought is not way to think of
How? When? (1-100) were (1-100). thought is true? true? this situation? 0-100

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