What To Try When The CBT Thought Records Don’t Work

The introduction of thought records was an innovative technical feature of Beck’s cognitive therapy for depression [1]. Amongst other techniques for exploring, examining, and ‘reality-testing’ automatic thoughts and images Beck recommended that “Recording cognitions and responses in parallel columns is a way to begin examining, evaluating, and modifying cognitions” [1]. He introduced the Daily Record Of Dysfunctional Thoughts which was designed to be used once patients were proficient at disputing thoughts. The Daily Record Of Dysfunctional Thoughts prompts patients to generate a ‘rational response’ to negative automatic thoughts. The columnar thought record format was developed further by Padesky and Greenberger [2] who added two additional columns to their design to encourage the expression and examination of evidence for and against the negative automatic thought.

Practically, thought records are often modified to facilitate their desired purpose – different types of thought records have been designed to better suit identification versus disputation for example – but at its core this cognitive restructuring technique is now a mainstay of modern cognitive behavioural therapy (CBT). Many patients find that recording and challenging their negative automatic thoughts is an enlightening process and countless thousands have been helped by learning this conceptually simple but simultaneously powerful technique.

However, most clinicians who practice CBT will have had the experience of teaching their patient to use a thought record to examine the evidence for and against a thought – but finding the technique unproductive. It can be disappointing and frustrating for patients and therapists when this core technique doesn’t help. Common difficulties occur when patients report only minimal emotional shifts, or say “It makes sense, but I don’t feel any different”, or “I know it but I don’t feel it”. Despite their apparent simplicity there are numerous pitfalls that even experienced cognitive behavioral practitioners can fall into when using thought records. In this article we will explore our top ten recommendations for what to do when the thought records don’t work.

1. Make sure that the thought is phrased correctly as a statement of fact

When examining the evidence for and against a negative automatic thought it is essential that the thought be in the form of a statement that the client believes to be true. Other types of thoughts are not amenable to thought records, or may initially be phrased in unhelpful ways that require reformulation. Phrasings that may prove problematic for the successful completion of thought records include:

• Thoughts in the form of a question
• “What if … ?” thoughts
• Thoughts referring to feelings
• Truisms

Thoughts in the form of a question such as “Why am I so useless?” are not a statement which the client believes to be true. Exploring the evidence for a thought phrased in this format has the potential to invite more questions than it provides answers. Thoughts in the form of a question can be more productively phrased as a statement, changing “Why am I so useless?” to “I am useless”, to which the client can assign a belief rating. A straightforward way of responding to negative thoughts in the form of a question is to simply ask your patient “How about if we rephrase that question as a statement?”, or “If we rephrased that as ‘I am useless’ how much would you have agreed with it in that moment?”.

Similarly, thoughts that begin with the phrase “What if … ?” indicate doubt that a patient may not actually hold. Statements such as “What if I need to leave and embarrass myself?” can be rephrased as statements of fact: the prediction “I will need to leave and embarrass myself” is more suitable for a thought record. Clinicians should also consider that when working with predictions shifting to experiential techniques such as behavioral experiments is often more productive than persisting with purely cognitive approaches.

If a thought just refers to feelings – for example “I feel angry / upset / sad” – then the patient will validly assign this statement a high conviction rating. There is unlikely to be convincing evidence that they don’t feel this way because if a person feels something then they feel it! (As an aside, this is a great reason why stating what another person’s behavior makes us feel is a great assertiveness technique – it’s hard to argue with a feeling). When a patient expresses a thought about how they feel it is best not to work with that thought directly, but instead to unpack the reason why the individual feels that way ¬– this unpacking can result in a testable thought. For example, when a friend failed to phone her, one patient recorded “I feel so sad, anxious, and disappointed” in her thought record. When her therapist explored this further she described how this friend’s actions often made her feel as though she were unimportant and likely to be excluded from the group. She described having an image of an event from childhood when she was excluded from a group of friends which, to her, meant “It’s happening all over again”. Once this painful and anxiety-provoking prediction had been unpacked she was able to work through this difficulty in a helpful way.

Finally, it is helpful for the therapist to consider whether a statement is a truism – could this thought conceivably be true for everyone? A statement like “Perhaps I might fail” could be true in so many situations that it is fairly meaningless. If your client expresses a thought that is so widely applicable to everyone then it is worth attempting to explore whether there is a more specific prediction that they are making.

Lesson: When helping patients to complete a thought record make sure that the thought to be tested is a statement of fact which they believe to be true. Don’t be afraid to explore further or to ask the patient’s permission to rephrase their thought.

2. Does the emotion match the thought?

A quick sanity-check when training patients to use CBT thought records is to ensure that the negative automatic thoughts and emotions are consistent. As a therapist you can ask yourself “How would I feel if I believed that thought in that moment?”. If the thought and emotion don’t seem to match one another then it is a sign that the client’s belief may need to be explored further until a thought has been identified which matches the emotions.

For example, Daniel completed a thought record as a homework task and recorded an event where he felt extremely angry while he was having dinner with his wife and children. He described having had the thought “They’re disappointed with me” which did not seem to match the level of anger which he reported. Daniel’s therapist asked him to close his eyes and replay the events from dinner time in his mind. During this slow exploration of the event Daniel reported that during the meal he had experienced an involuntary memory of a moment during his week at work where he had been demeaned by a critical manager. When he experienced this image during the family dinner, Daniel’s negative automatic thought was “They take me for granted and don’t understand what I put up with in order to provide for them” which was much more consistent with the anger he was reporting. He and his therapist were then able to examine the reasons why Daniel felt taken for granted, and then to explore strategies to have his needs met more helpfully.

Patients may find some thoughts and emotions more difficult to report than others. Charlotte had grown up in a critical household and had become a person who always tried to pre-empt criticism. Her tutor criticised an assignment on which she had worked extremely hard and she described having the negative automatic thought “I’ll never be good enough” and feeling completely disgusted and full of self-loathing. Her therapist suspected that the magnitude of emotion Charlotte was reporting did not seem to fit the thought and gently explored further. With help, Charlotte was able to describe how in that moment she remembered thinking “I’m totally pathetic” which was a label that her mother often applied to her.

Lesson: Always try to put yourself in the client’s shoes and think “How would I feel if I believed that thought in that moment?”. If you notice a mismatch in emotional tone then consider exploring the negative automatic thought further.

3. Are you sure this is the thought that is really bothering the client?

Sometimes if completing a thought record has failed to lead to a meaningful emotional shift then it can be worth questioning whether you have identified the thought that is truly hot for this individual. Working on the right thought at the right time can lead to the most ‘bang for your buck’. Beck and colleagues [1] warned of being too superficial when practising cognitive therapy:

“It is crucial that the neophyte recognize the importance of fully ascertaining meanings. Although correcting unrealistic automatic thoughts is an important element in treating a patient, the totality of the meaning of the patient’s experience is crucial. At times, the meanings people give to a situation may not be fully formulated but rather will have to be drawn out by the therapist. For example: If a patient receives a rejection of a manuscript, his automatic thought may be “I’ve failed at this. It’s been a waste. I’m never going to write anything again.” However, if the therapist asks the patient “What does this mean to you in terms of your future, yourself, and your experiences?” he is likely to get even more salient material. The patient might say, “It means I am totally inadequate, I will never be able to do anything. I’ll never advance in my career. … I will never be happy.” By relying exclusively on the immediate raw data of the automatic thoughts, the therapist misses the crucial—but-unexpressed meaning: namely, the patient’s anticipated consequences in terms of the rest of his life.”

Some reasons that you may not have identified the hot thought relating to a situation include:

• clients might experience some thoughts as shameful and be reluctant to disclose them to their therapist;
• clients might experience their thoughts in the form of images which require unpacking before they can be worked with;
• clients might report a thought as something other than a statement of fact that they believe in.

If you suspect that you might not be working on the thought that is really concerning your client here are some things that you might try:

• If you suspect that you are missing some information then you might ask “Some people have thoughts that they are reluctant to disclose, perhaps because they worry what others might think of them. Without feeling like you have to tell me what they are, have you ever had any thoughts like that?”. Sensitive and gentle questioning can open up a pathway for conversations about topics that clients may have considered taboo or un-discussable.
• Identify multiple automatic thoughts that occurred in that situation and take ratings of each for believability (“How much do you believe that?”) and the intensity of the emotional reaction (“How strong is the feel that evokes in you?”). These ratings can be helpful guide as to your client’s core concern.
• Ask the patient directly about mental images as well as thoughts – some people interpret ‘thought records’ too literally and assume it means only verbal thoughts. If they report an image or memory you can try asking “What did that image mean to you?”, “What did it say about you?”, or “Can you tell me what is so powerful or you about that image? Why does it evoke such a strong pull for you?”.

Lesson: Check that the thought your patient wants to work with really concerns what is bothering them. Give them the opportunity to disclose topics that they might otherwise be cautious about discussing.

4. Check your formulation for worry

It is often instructive for therapists to ask themselves what kind of thoughts they are trying to work with. The types of thoughts that work best with thought records are statements of fact that the client believes to be true, automatic negative self-judgements, and negative predictions. It is important to remember that some types and styles of thinking are not amenable to a classic evidence-for-and-against-the-thought approach typified by modern disputation thought records.

One good example of an incompatible style of cognition is worry in generalized anxiety disorder (GAD). People with GAD experience worries about hypothetical future events which tend to ‘chain’ together. When therapists choose to explore and challenge the content of worries a common experience is that once one worry is addressed the client does not experience lasting symptom relief or insight but instead quickly moves on to the next worry. Importantly, a diagnosis of GAD is frequently missed in clinical practice. In the case of GAD the expert advice is to work with the worry process more than the worry content [3].

Lesson: Make sure that the thought you are working on is not part of a worry chain. Indicators that warrant further investigation for GAD are multiple “What if …?” statements, and frequent shifting of topics of concern.

5. Have you identified the distortions in the thoughts?

Some patients struggle to see why they should go through the (effortful) process of exploring and challenging their thinking. Without client motivation to change no amount of therapist effort can lift their burden. As one technique for increasing client motivation David Burns recommends helping clients to identify the distortions in their thinking [4]. The rationale is that if patients can recognise their thinking as distorted then they are more likely to be motivated and able to change it. Therapists should ensure that they are familiar with the unhelpful thinking styles that can drive depression and anxiety.

Lesson: Patients can find it normalizing to understand more about cognitive distortions and the ways in which our thinking can become ‘wonky’. Conceptually, identifying biases in our thinking is easier than generating alternatives. Take the time to teach your patient about the common unhelpful thinking styles then consider helping them to identify the biases in their thinking by practising with the Thought Distortion Monitoring Record. Rather than jumping straight to disputation this tool helps people to identify what biases might be present in their thinking.

6. Are you working on a core belief?

CBT theory proposes that there are 3 levels of cognition [4]:

• Negative automatic thoughts which are activated involuntarily in response to certain situations.
• Dysfunctional assumptions or intermediate assumptions are “rules for living” that people adopt in order to protect themselves from confronting core beliefs.
• Core beliefs (schemas) are deeply held beliefs about the self, others / the world, and the future.

Negative automatic thoughts are situation-specific and relatively amenable to quick cognitive restructuring. On the other hand core beliefs are more deeply held and more resistant to change. Core beliefs are generally formed early in life and are absolute statements. They are often expressed as short, simple statements, seemingly of fact, such as “I’m bad” or “I’m unlovable”. At first glance it can be difficult to tell the difference between a negative automatic thought and a core belief. Clues that you might be working with a core belief include [6]:

• the thought/belief is phrased as a short absolute statement;
• the thought/belief provokes a high level of affect;
• similar thoughts/beliefs are present across multiple thought records;
• examining the evidence for and against the thought/belief fails to lead to a significant change in affect;
• using the down arrow technique (by repeatedly asking questions such as “If that were true, what would it say about you?”) has ‘bottomed out’ at the thought/belief.

If a therapist identifies core beliefs whilst in the process of identifying and challenging negative automatic thoughts then it is helpful to be guided by your case conceptualization and treatment plan. Core beliefs are responsive to change methods such as continuum scaling, or the collection of evidence as a counter but they are typically slower to change than negative automatic thoughts. If negative automatic thoughts appear to be a driving factor in a client’s anxiety or depression then it can be appropriate to acknowledge the presence of a core belief and then refocus on negative automatic thoughts until a client can work confidently to identify and challenge them. Once clients have learned this skill it may or may not be necessary to revisit and work at the level of core beliefs.

Lesson: Be on the lookout for core beliefs which may appear as succinctly-phrased statements of ‘fact’, appearing across multiple thought monitoring records, and which are slower to change. Be wary of moving too quickly towards schema-change techniques unless your clients are already well-practised in using thought records and disputation.

7. Take a wider perspective

Some clients can find the process of examining evidence for and against a thought somewhat restrictive. This was never Beck’s intention, he wrote:

“…the reductionist conception of cognitive therapy view this approach as a series of steps executed along the style of a waltz or a tango. Actually, cognitive therapy is a broad system concerned with providing specific procedures to identify and modify the patient’s ‘personal paradigm’. A crucial part of therapy, thus, consists of the therapist’s obtaining adequate information, so that he can step into the patient’s world and can experience the way in which the patient organizes reality” [1].

One way of rolling with resistance but staying with the concept of exploring alternative perspectives to our negative automatic thoughts is to take a wider perspective. Instead of getting hung up on disputing evidence for and against, therapists can explore the thought process more broadly by asking:

• Is this a helpful way of thinking?
• What are the advantages for you of thinking this way?
• What would be a more helpful way of thinking?
• What would you say to a friend who was thinking in this way?
• Does this way of thinking form part of a pattern?

Lesson: Thought records in CBT are sometimes presented solely as a method for examining the evidence for and against a negative automatic thought. Therapists new to the technique can often view thought records as a task to be completed or a box to be ticked along the way to recovery. A more helpful way to view thought records in CBT is to consider them as an opportunity to ‘dive into’ a client’s way of thinking and then to examine the style of that thinking with an objective lens.

8. What tone of voice is your client saying their new thought in?

Paul Gilbert, famous for the development Compassion Focused Therapy, discusses how important tone of voice is if clients are really going to connect with corrective information [7]. As an experiment try saying the phrase “It wasn’t your fault” out loud to yourself in two tones of voice:

• first say it in a sneering condescending tone of voice;
• now say it in a warm compassionate tone of voice.

What do you notice? Which tone of voice would you want to be soothed in? Many patient’s internal dialogue is one characterised by a harsh tone, and if this is the case then the tone may be acting to undo all the positive work of the cognitive restructuring. It is a helpful practice to ask your patient to say their new thought out loud, and to find out more about the tone of their inner voice. For example, if a patient experiences their inner voice as harsh critic, perhaps in the voice of a critical parent, then it may be necessary to change how they speak to themselves prior to using cognitive restructuring to change what they say.

Lesson: Explore how your patients speak to themselves internally. Some people need to change the tone of their inner dialogue before being able to benefit from changing what they say.

9. Does this patient have sufficient emotional memories of soothing to draw upon?

A refrain often heard by therapists at the end of an attempt to use thought records is “I know it but I don’t feel it”. What patients often mean is that the facts presented make rational sense but they are not resonating emotionally with them. Dr Deborah Lee, an expert in compassion focused therapy, often explains that the rational process of cognitive restructuring relies upon the individual having relevant emotional memories of being soothed that can act as a template for how to feel when presented with new (soothing) information. Without the solid underpinning of warm emotional memories the new rational information is not built upon a strong foundation and the patient will not identify with it emotionally. One approach from CFT to help people around this roadblock is to engage in physical soothing exercises (e.g. soothing rhythm breathing), and imagery exercises (e.g. imagining myself at my best) to engage the kindness/soothing system before attempting to engage in cognitive restructuring. Therapists who use these techniques often report that when their patients are in a physiological state and ‘mindset’ of soothing then they are more receptive to alternative ways of viewing a situation.

Lesson: Is there evidence that this patient is able to identify with the idea of being soothed? Do they have emotional memories of soothing which might act as a safe foundation for changing their mind? Were their early experiences characterized by the experiences of kindness and nurturing that might allow them to easily feel safe and soothed?

10. Are thought records the most appropriate intervention for what you are trying to achieve?

Although many cognitive models highlight the centrality of negative beliefs and appraisals it does not follow that thought records are always the most appropriate intervention. When conceptualizing a patient’s difficulties it is crucial to consider whether negative automatic thoughts are really driving their distress, or whether other unhelpful behaviors are more fundamental to the maintenance of their problems. Thought records are sometimes introduced as a data-gathering exercise to aid case formulation, but this does not mean that traditional disputation is the most appropriate intervention. Indeed, there is evidence from a number of small research trials that behavioral experiments are a more powerful intervention than thought records [8].

For example, when she started therapy Clare often found it difficult to articulate what she was experiencing. In the assessment phase of their therapy she and her therapist used simple thought records as a way of exploring how she experienced difficulties throughout her week. Clare frequently recorded the negative automatic thought “I’m ugly” across a variety of situations. Rather than examining the evidence for and against this appraisal Clare and her therapist spent time exploring how Clare responded to this thought. Clare’s therapist suspected body dysmorphic disorder and they found that they got more clinical mileage from framing this belief in a ‘Theory A: “I’m ugly” / Theory B: “I worry that I’m ugly”’ format. They found that interventions such as surveys and behavioral experiments were helpful for Clare to reality-test her appraisal.

Lesson: Cognitive therapists often focus too strongly on cognitive interventions. If negative automatic thoughts underpinned by distorted thinking styles are the primary driver of distress then thought records can be an appropriate intervention, but negative appraisals also drive unhelpful behavioural and attentional processes. Careful case conceptualization can help therapists to identify the most helpful intervention.

References

[1] Beck, A. T., Rush, J. J., Shaw, B. F., Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

[2] Greenberger, D., & Padesky, C. A. (2015). Mind over mood: Change how you feel by changing the way you think. Guilford Publications.

[3] Wilkinson, A., Meares, K., Freeston, M. (2011). CBT for worry and generalised anxiety disorder. Sage.

[4] Burns, D. D. (1989). The feeling good handbook: Using the new mood therapy in everyday life. William Morrow & Co.

[5] Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. Guilford press.

[6] Wenzel, A. (2012). Modification of core beliefs in cognitive therapy. In Standard and innovative strategies in Cognitive Behavior Therapy. IntechOpen.

[7] Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41.

[8] McManus, F., Van Doorn, K., & Yiend, J. (2012). Examining the effects of thought records and behavioral experiments in instigating belief change. Journal of Behavior Therapy and Experimental Psychiatry, 43(1), 540-547.

APA reference for this article

Whalley, M. G. (2019). What to do when the CBT thought records don’t work. Psychology Tools. Retrieved on [date], from https://www.psychologytools.com/articles/what-to-do-when-the-cbt-thought-records-dont-work/