The Middle Phase of Treatment

Once the patient is more active and involved in his/her environment, the focus of therapy quickly shifts to cognitive assessment and restructuring. The term "cognitive restructuring" refers to a large number of interventions that generally focus on situation-specific (as opposed to underlying, broad, or trait-like) negative thinking. As noted earlier, depressed patients can perceive the world accurately or in a distorted fashion (Beck et al., 1979; J. S. Beck, 1995; Clark et al., 1999), and the identification of a variety of cognitive distortions and the use of clinical tools to challenge distorted automatic thoughts (ATs) are hallmark features of CT. As such, a significant part of CT for depression is spent educating patients about this process and helping them to recognize negative ATs and to evaluating them in real time, so that the spi-raling effect of these thought patterns is disrupted.

The role of negative ATs in depression is usually discussed in the first session, when the therapist provides a broad overview of CT. Therefore, when the therapist is prepared to actually identify and work with a specific negative AT, the patient has already been introduced to the concept. At the point in treatment when the therapist begins to work on cognitive restructuring, it is often particularly useful to teach the patient to ask at the time he/she notice a shift in mood, "What was going through my mind?" (J. S. Beck, 1995). This question helps the patient to recognize that ATs mediate emotional and behavioral responses to life events. Some therapists also assign reading, which can help the patient to recognize this process (Burns, 1980; Greenberger & Padesky, 1995). If it seems appropriate, some therapists may also reprint and review with the patient a list of common cognitive distortions (J. S. Beck, 1995, p. 119).

A common intervention in CT for depression is use of the Dysfunctional Thoughts Record (DTR; see Figure 1.3; note that other variations exist). Once the patient has been introduced to the concept of negative ATs and has recognized its possible relevance to him/herself, the therapist suggests a more formal written record of these processes, to help both patient and therapist to examine this process more fully. The therapist introduces the DTR, and encourages the patient to start to write down both events that trigger negative reactions, such as negative ATs, and such as negative emotional and behavioral reactions themselves. After practicing with the DTR in session, the patient is given the homework assignment of completing the DTR between sessions, when he/she notices an increase in depression (or other negative moods). Subsequent sessions are spent reviewing the DTR, including problems with its completion, and helping the patient to increase his/her understanding of the nature of, and associations among, problematic or triggering events, ATs, and changes in mood and behavior.

Once the patient has some fluency with the DTR, and can consistently collect this type of information, it is possible to move to the step of intervening with these thoughts. Interventions generally involve the patient reconsidering his/her negative thoughts based on three sets of questions generally framed as "What's the evidence?," "Is there an alternative?," and "So what?" In some cases, one of these questions has the most utility, but it is useful to introduce each line of questioning, so that the patient has the full set of skills before the end of treatment. Each question is discussed briefly below.

The "What's the evidence?" question requires the patient systematically to evaluate the facts, data, or evidence related to each thought. Implicit in this question is a stance that cognitive therapists do not accept a thought as true simply because it has occurred. The idea that "a thought is not a fact" is in fact itself a metamessage that supports a more detailed analysis of negative thinking. Sometimes a problem has a high degree of evidentiary support,

Date and Time


Automatic Thoughts

Emotional Responses

Behavioral Responses

Cognitive Distortions

Alternative Thoughts

Alternative Responses

Note. To generate alternative thoughts, consider the following:

1. The evidence that supports or refutes the original automatic thoughts,

2. Whether any other more reasonable or alternative thoughts are possible in the situation, or

3. Whether the original meaning or importance of the situation is the only possible way to think about it.

FIGURE 1.3. The Dysfunctional Thought Record.

which may suggest the need for a more problem-solving orientation relative to these negative thoughts. In depression, though, it is common for patients to exaggerate or overstate the negative aspects of an event, or to minimize the positive aspects. In these cases, examining the evidence that supports and refutes the original negative AT can be very helpful, both to expose patients to this line of inquiry about their thinking and to generate a realistic appraisal of the positive and negative features of an event or situation.

Sometimes the process of examining the evidence related to a negative thought reveals that the patient clearly does not have much evidence on which to base his/her negative AT. Mind reading and jumping to negative conclusions, two common distortion patterns seen in depression, are typically based on insufficient evidence. Such revelations can lead to the assignment of behavioral experiments as homework to establish more fully the "facts" related to the negative thoughts. Such homework increases the patient's contact with his/her environment and provides a more realistic basis on which to deal with problems.

The second question, "Is there an alternative?" requires the patient to consider whether there is an alternative thought or explanation to the original thought. This alternative sometimes become obvious once the evidence related to an AT has been examined. Thus, if the patient's original negative thoughts can be demonstrated to be out of alignment with the "facts," then a more realistic alternative can be generated (note, however, that the cognitive therapist aims not for an alternative that is distorted in a positive direction, but for one that is in keeping with the available information).

In other cases the situation is ambiguous and open to alternative interpretations, thus making it possible to generate a series of alternative interpretations or ATs. A therapist pointing out the choice of alternative thoughts is itself sometimes revelatory to patients, and the exercise of generating these alternatives often takes the "sting" out of the first, typically depressive, cognition. Some patients report that with the recognition of alternatives, the original thought is just one of many, that has no special priority or valence. In other cases, the patient may benefit from being asked how someone else might interpret the situation. The therapist can also offer some alternative ideas, although he/she must always be sure to evaluate whether patients accept or reject these alternatives, and why. When the interpretation of the event remains unclear, the therapist might design homework to collect the necessary evidence, then weigh these alternative ideas and see which one best fits the facts.

The third question used to explore negative ATs is "So what?" It requires patients to explore the meaning they have assigned to the AT, and to determine whether this is the only possible meaning. For example, a depressed student who fails an examination might jump to the conclusion that his academic career is doomed, and that this dismal career path confirms his inadequacy. He might be asked to reconsider whether the meaning he has attached to this interpretation is valid, however. In effect, the therapist is asking him to step outside his usual way ofviewing things, to say to himself, "So what if I failed this exam?", and to realize that he does not have to jump to the conclusion that because he has failed, he has no academic future or career prospects. It should be recognized that this is a difficult question, though, because it requires the patient to adopt a different perspective on his/her difficult situation. Asking this question is almost like asking the patient to suspend his/her usual beliefs about the world and to determine whether the meanings he/she first applied to the event are valid.

The "So what?" question should not be employed too early in the treatment of depression, because it often exposes the patient's core beliefs or meaning structures. If this work is done too early in therapy, it may confirm for the patient the hopelessness of his/her situation and core beliefs. Depressed patients often struggle with accepting alternative thoughts that are not consistent with being depressed, so patients may perceive the "So what?" question as the reflection of an uncaring or misunderstanding therapist, if it is employed before the client-therapist relationship has time to solidify. Even when examining specific negative ATs, the "So what?" question is typically used only after the first two sessions of therapy have been completed, because addressing this question too early can lead to a kind of rigid defense of the original ATs. Also, changing negative ATs based on the first two questions is somewhat more straightforward than an examination of the meanings a patient has assigned to an event.

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