Cognitive
therapyDealing with worries and concerns
| Type of worry or concern | Realistic | Unrealistic | |
| Examples |
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"Depressive thinking" (may pre-date episode or be maintaining it or both) |
| Strategies | Coping strategies | Problem solving | Cognitive strategies |
Stages of problem solving
Steps
Enable the patient to:
- define the goal;
- brainstorm options;
- explore the pros and cons of each option;
- choose the desired option;
- go through the steps required to carry out option and achieve goal;
- consider the "worst case scenario" (stress inoculation).
Get the patient to do the work (patient-centred). If he/she cannot think of options try to avoid suggesting alternatives yourself. It may be easier if, when the patient is severely depressed, he/she is on medication. Problems may not be soluble (see coping strategies).
Counselling depressed patients
Dealing with realistic worries
Coping Strategies
- Focus on the positive as much as possible;
- Help the patient to realistically adjust his or her expectations;
- Offer appropriate reassurance;
- Provide empathy, encouragement and support. Empathy should be verbalised to be most effective (see above).
- At all times remember to use a negotiatory style.
- What are the potential sources of outside help and support?
- How can they be used?
- How has he/she managed on previous occasions?
- What do they want to achieve this time?
- What steps can be taken to ensure that this does not happen again? (relapse prevention).
Ways of increasing or modifying activity
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Automatic Thoughts
- "There is nothing I can do about"
- "I'll never be any good about it"
- "It's always my fault"
- "Everybody hates me"
Thinking errors in depression
- All or nothing thinking: "Unless I do it perfectly there is no point in trying..."
- Overgeneralization: "I'm always making mistakes..."
- Mental filter: "Nothing ever goes right at work ..." Discounting the positive: "She was only feeling sorry for me..."
- Mind reading: "Everyone thinks I'm a wimp ..."
- Personalization: "They always pick on me..."
- Catastrophizing: "Failing my driving test will be a disaster and I'm bound to fail..."
Eliciting negative automatic thoughts
- Work through an example:
- ask about thoughts which come into mind
- link thoughts to feelings
- Ask what thoughts come to mind here and now in the consultation when you are talking about a difficult topic - link thoughts to feelings
- Keep a record of thoughts
- Willingness to keep a record can be a good test of motivation.
Intervening with automatic thoughts
- Stay neutral when exploring evidence for and against the thought
- Your role is to ask questions, not to provide answers
- Ask "How?" and "What?" questions rather than "Why?"
- Use a negotiating style
- Emphasize the joint role in finding the best way of examining the evidence and challenging the automatic thoughts
Failing to do the above may mean that your well-intentioned efforts come across as "pull yourself together".
Key Strategies:
- Questioning the evidence
First of all question the evidence for the accuracy of the thought:- "What leads you to think this?"
- "What's the evidence for and against?"
- "What other factors might be playing a part?"
- Hypothesis testing
Is there any way that you can test out your hypothesis? - Generating alternatives
What are the alternative explanations?- "Can you think of another way that you can look at this thought?"
This is called generating a rational response in cognitive therapy jargon.
- "Can you think of another way that you can look at this thought?"
- Reattribution
Challenge tendency to relate external events to self. Encourage correct apportioning of "blame" rather than blaming self for everything.
Provide as much support and encouragement as you can. Encourage appropriate assertiveness. Encourage taking credit for the positive aspects of life where this is clearly due.