Checking it out

  The checking it out technique is particularly useful when an individual is uncertain about what another person is thinking. This can done by simply asking people what they are thinking rather than jumping to conclusions about their motivations or mind reading. Checking things out can provide an immediate and very effective way of challenging negative assumptions.

Estimating probabilities

  Estimating the probability of both negative and positive interpretations of an event is a particularly powerful technique for challenging anxious predictions. By assessing both interpretations it does not reject the original negative interpretation, unlikely as it might be, but contrasts it with more likely interpretations. This approach trains the individual to consider thoughts as interpretations of reality rather than reality itself and helps them reach more rational conclusions, the outcomes of which can then be subsequently evaluated. For example, if someone is anxious about flying, it is possible to compare the probability of having an accident while flying, to the probability of having an accident in a car, and get a sense of proportion about the risk involved.

Reattributing meaning

  The technique of reattributing meaning is particularly helpful for challenging beliefs about guilt and blame. Rather than blaming oneself, the reattribution technique encourages the individual to consider external environmental factors as causes for negative outcomes rather than just internal personal factors. Also, even if the individual was responsible to some extent, they are encouraged to ask the question ‘Are the consequences of this really as bad as they seem?’ and consider how might they feel about these events in one day, one week, one month or six months’ time.

Conducting behavioural experiments

  Challenging cognitive distortions need not take place only at a cognitive level. The process can be greatly enhanced by the use of some more empirical behavioural strategies such as conducting behavioural experiments for example. This involves the setting up of ‘mini experiments’, whereby the patient’s original negative thoughts and the new alternative positive ones are treated as two possible alternative hypotheses predicting an outcome. The patient is then encouraged to test these out in a real life situation and to establish which of the two alternatives is more accurately predictive of the outcome.

Case study: Sarah

  This case study has been included to illustrate the use of the cognitive techniques described above to identify, label and challenge dysfunctional thinking patterns.

Sarah was a 32-year-old nurse who had just been promoted to a post as a nurse in charge of an intensive care unit. It was the week before she was due to start in her new job and she was feeling particularly anxious about it. As a result of her early life experiences and upbringing, Sarah was not a very confident individual and was prone to experiencing quite a lot of self-doubt and worry about her own capabilities, even though she was in reality quite a high achiever. As the start date got nearer, she became increasingly anxious, verging on panicky. Sarah was encouraged to commence a thoughts diary in order to identify the unhelpful thinking patterns which were leading to her feeling anxious and panicky. A copy of one of the entries in her thoughts dairy is provided in Table 9.4.

Table 9.4 An example of Sarah’s thoughts diary

 

  The example in the thoughts diary reported that Sarah had experienced an anxiety attack in a shoe shop and had to leave the shop because of it. The triggering event was identified as attempting to buy a pair of shoes for starting her new job the following week. The triggering thought which led to her anxiety was ‘Gosh, this time next week I will have started in the new job’. Through the process of self-monitoring her thoughts using a thoughts diary, Sarah was able to identify and rate a number of dysfunctional thoughts associated with her anxiety. These included ‘I will not be able to cope’ (80 per cent), ‘I will make a mistake’ (75 per cent), ‘I will show myself up’ (80 per cent), ‘I will get the sack’ (80 per cent) and ‘People will think that I am not up to the job’ (90 per cent). She labelled these distortions as examples of catastrophic thinking, jumping to conclusions and mind reading. By looking at the evidence for and against each of the NATs listed, Sarah was able to identify alternative more positive and rational beliefs to challenge them. As a consequence of successfully challenging her anxious thinking patterns Sarah’s overall level of anxiety reduced considerably and she felt more able to cope.

In addition, Sarah set up a behavioural experiment to test her positive and negative predictions about her new job. Her positive predictions were those beliefs she had reached through the process of challenging her NATs that she would be able to cope, would not get sacked, would not make a mistake or show herself up, and that people would think that she was capable of doing the job. Her negative predictions were that she would not cope, that she would get the sack, make a mistake or show herself up, and people would think she was not up to the job. She tested out the accuracy of these predictions two months after commencing her new job and the outcome was that the evidence completely supported her positive predictions and invalidated the negative ones. Not only had she settled well in her new job, but also she had not made any significant mistakes and had received lots of positive comments about her performance at work from her manager, colleagues and patients. For Sarah, the behavioural experiment had provided evidence that she was more capable than she had initially believed and it disconfirmed her original negative beliefs about herself and others. As a result of the positive outcome of the experiment, she began to feel more confident and relaxed at work.