Figure 4.3

Original dysfunctional thought record.

Figure 4.3 shows an example of the type of information that can be collected on the DTR. As shown in the figure, the patient identified a difficult situation and recorded her emotional experiences. The automatic thoughts are generally consistent with the emotional experiences that she recorded, although some do not seem tied to the emotions that were listed. In the example “Why can’t I find people to hang out with?” it is unclear what thought or image might have been behind the anger reaction. In such a case, the cognitive therapist would likely inquire further. First, the therapist would get a detailed description of the event to be able to imagine himself or herself in the situation. Second, the therapist would ask for more information about the emotional experiences and the severity. Often the therapist will distinguish among the first and subsequent reactions to distinguish the primary emotional experience from any secondary reactions. Finally, the therapist will help the patient in recalling the thoughts he or she had in the situation (not the patient’s ideas of what thoughts they might have or should have had). Again, the most strongly held or primary automatic thought may be distinguished from secondary metacognitions or from less important automatic thoughts. It might be helpful to draw lines on the DTR to connect different automatic thoughts with the emotional consequences that they engendered.

The original form of the DTR has some limitations. First, it fails to place the hypothetical relationship among variables in their proper sequence. According to the cognitive model, different emotional reactions result from the automatic thoughts that arise in varying situations. A conceptually more appropriate format for the DTR would be one in which the situation is listed first, followed by the automatic thoughts, and then the emotional consequences. Second, the original DTR does not provide a column for the behavioral consequences of different negative automatic thoughts. Although patients often focus on the content and valence of their emotional reactions to different situations or triggers, the cognitive model of change invokes behavioral strategies as part of the interventions. Knowing the patient’s typical behavioral responses to negative automatic thoughts can be important in helping the therapist plan the appropriate interventions. A more theoretically consistent and complete form of the DTR might therefore be the one that is presented in Figure 4.4. In this case, the avoidance behaviors that are identified may become important because the lack of planning by the patient may create a self-fulfilling prophecy in which he or she dislikes weekends because of their meaning and emotional emptiness, but then fails to make plans that could reduce that response pattern.

Figure 4.4

Modified dysfunctional thought record.

Working With Automatic Thoughts

Once the patient begins to notice and record the automatic thoughts that occur in different situations, the therapist encourages him or her to bring them into treatment. The therapist needs to support this activity because simply exposing the thoughts can be difficult for the patient. For example, if some of the patient’s thoughts have little evidence to substantiate them, he or she may be afraid to write them down for fear that the therapist will think them foolish. Some patients can see ways in which their thoughts are illogical or “wrong,” and they might try to quickly change or suppress certain thoughts and not give the therapist the chance to fully understand their thought process. The therapist should treat the thought records factually and in an investigative manner. The therapist should communicate the desire to understand the patient without judgment about the patient’s thought patterns. Sometimes it is important for the therapist to explain to the patient the value of recording accurate and complete information so that the interventions that will best help the patient can be planned.

One of the virtues of cognitive therapy is the multitude of interventions that are available for working with negative thoughts (D. J. G. Dobson & Dobson, 2009; Leahy, 2003; McMullin, 2000; W. O’Donohue & Fisher, 2008). Because most patients have many negative automatic thoughts, the selection of the most useful intervention for a given automatic thought can be daunting for beginning therapists.

The thoughts connected with the most distressing situation (the “hot cognitions”) should be chosen for interventions. In addition, cognitive therapists generally focus on the most distressing or dysfunctional automatic thought within any given situation. Cognitive therapists try to solve problems as efficiently as possible even at the level of within-session decisions about targets of intervention. Picking the most distressing situation from a DTR and working it through fully is generally more effective than addressing several negative thoughts more superficially. If other difficult situations or thoughts exist, they will likely recur on a future thought record and can be worked on at that time.

The above discussion regarding the collection of automatic thoughts demonstrates that no one ideal or preferred method for doing this work exists in cognitive therapy. Patients can self-report their automatic thoughts, collect counts of automatic thoughts, use forms, write notes to themselves on a pad or paper diary, use an electronic diary, or create spreadsheets or notepads in their personal computers. The important principle is that these thoughts are attended to and reported in therapy sessions so that the therapist can understand the patient’s thoughts and plan an intervention program. Although certain patterns of automatic thoughts are typical of patients with the same diagnoses or problems, every person is an individual, and understanding the particular mechanisms by which each patient experiences his or her problems is a critical part of the therapeutic process.