Figure 4.5

Completed dysfunctional thought record.

Developing Positive Thoughts

The interventions described so far have focused on the identification and reduction of negative thoughts. Cognitive therapists also encourage the development of positive thoughts. For example, if a mother expresses the thought, “I worry that my child will become sick and I won’t know what to do,” the therapist could focus on the worry-related thoughts and sense of incompetence that generate this emotional response. However, this type of worry can be generated by a deep concern and love for one’s child and a desire to protect the child from harm. Thus the therapist could focus on the positive aspect of the cognition and help the patient develop alternative ways of expressing her love and concern rather than worrying. This type of intervention is sometimes referred to as reframing and can be effective if the patient is open to this alternative way of thinking about a situation.

A discussion of negative thoughts and their effects can be used as a springboard to a discussion of the effects of positive thoughts. Patients can be encouraged to experiment with positive thoughts in their day-to-day lives to enable them to see what emotional and behavioral consequences are engendered. For example, a depressed patient may have learned that simple actions, even if they do not overcome an entire problem, lead to positive emotions and a sense of progress. The patient could generate a summary statement such as “I just need to try.” The statement could be written on a flash card or in some other reminder system that the patient could use when confronted with a difficult task. The positive statement is not the same as a self-affirmation (McMullin, 2000) because the positive statement is based on the patient’s own experience and will have a particular meaning for him or for her. A positive thought needs to resonate with or be believable to the patient at some level before it is used in homework or other assignments.

Meaning-Based Interventions

The third class of interventions used in working with automatic thoughts is the examination of the meanings attached to or the inferences that are drawn from different experiences. Often the inferences are themselves automatic thoughts, which are about either other thoughts or the emotional and behavioral consequences of the thoughts. These metacognitions are in effect another level of thought and are generated in response to the original automatic thought and the related experiences. For example, a single man may attend a social event and approach someone whom he finds attractive, only to be rebuffed. The experience might lead to automatic thoughts such as “I am not very attractive to others” or “I made a fool of myself.” Once the thoughts emerge, the patient may experience embarrassment, and when he notices, he might generate secondary thoughts such as “I am a social misfit” or “Why would anyone want to be with me when I am so easily embarrassed?” These secondary automatic thoughts, or metacognitions, might be generated from either the same core beliefs that prompted the initial thought or from a related but deeper level of belief or schema.

When a cognitive therapist asks the patient questions about the meanings or inferences that have been drawn from automatic thoughts, the discussion often moves from situation-specific thinking to more general and trait-like patterns of thought. The technique, known as the downward arrow (J. S. Beck, 1995), has been well documented. Rather than disputing or challenging negative thoughts, the therapist asks the patient to assume that the first automatic thought is true or valid, then further queries the patient about the inference or conclusion that he or she has drawn. The therapist’s question can be described as the “So what?” question, as in “So what if your thought is true? What would that mean about you?” The patient’s response is then questioned in the same way, and the patient draws increasingly broad implications until it seems that a final, “deepest” meaning or inference is obtained. Figure 4.6 presents an example of the downward arrow for a college student who may have failed her midterm examination.