Elia is a 25-year-old single woman who lives with her parents. She combines her final year of studies in Podiatry with a part-time job as a shop assistant in one of the shops in the city centre of a well-known youth clothing brand. However, when she comes to the consultation, she tells me that she has been on sick leave for two weeks.
According to Elia, it all started about six months ago, when two factors came together: the breakup of a long relationship and concern about their job opportunities as they see the end of their career in sight.
Elia presents moderate depressive symptomsa high tendency to perfectionism, fear of failure, constant worry about whether each decision she makes is the right one or not, feelings of inefficiency, guilt and frustration, as well as low self-esteem. She says that, four years ago, she had a similar episode that “I got over on my own” but that has left her with worries that do not go away and that now “overwhelm” her again, with increasing intensity. She believes that the time has come when they have ended up overwhelming her.
What we call automatic thoughts
They are negative cognitions, that is, ideas, personal constructs, images, beliefs, expectations, attributions, interpretations, self-instructions and schemes that modulate behavior through emotions and, therefore, are key both in the appearance of various disorders and in the process of therapeutic change.
Its main features are:
- Their appearance does not have a prior reasoning process, therefore, we could say that they are “reflexes”.
- They are irrational and, when negative or distorted, they are inadequate.
- The person accepts them as valid because they seem plausible.
- They are involuntary and this makes it difficult to stop them and, therefore, they often become recurrent.
Within automatic thoughts we can find:
- Cognitive distortions.
- Negative thoughts.
What types of cognitive distortions exist?
According to Beck (1983), automatic distortions are systematic errors:
- Arbitrary inference. It consists of drawing conclusions that have no objective evidence. For example, in Elia's case, every time someone looks at her they can say to themselves “He doesn't think well of me” Do you have any reason to think badly?
- Mind reading. It consists of concluding, without objective evidence, that the other person thinks badly of us. For example, a student with social phobia who asks a question to his teacher and the teacher frowns, thinks “He thinks I'm a pain for asking” Could it be that he had a headache?
- Fortune teller's mistake. Anticipating, without objective evidence, that things will go wrong in the future. For example, an anxious woman getting on the subway thinks «It's sure to crash and We will all die” Can we guess the future?
- Personalization. Attributing external phenomena to oneself when there is no objective data. For example, a man with depression goes into a therapist's office and notices that the therapist is not taking notes, thinking “I am so simple that I am not interesting”Could it be that he was recording the session and that's why he wasn't taking notes?
- Selective abstraction. Biasing information in a way that is consistent with a dysfunctional schema, ignoring information that contradicts it. For example, a boy with a phobia of flying, after a turbulent flight, thinks “airplanes are not safe.” But it arrived safely at its destination, right?
- Overgeneralization. Apply the appropriate conclusions for a specific case to all similar experiences based precisely on these similarities. For example, a girl has to wait for her partner – usually very punctual – but that day he is late and thinks, “I always have to wait for myself” Could it be that we girls tend to make our partners wait and not the other way around?
- Magnification. Over-attending to and exaggerating the importance of negative aspects of an experience. For example, a worker makes a mistake while making a calculation. When he realizes this, he thinks “They won’t trust me anymore” Does one mistake – who is free of them – ruin years of successes?
- Minimization. Underestimating the importance of positive experiences. For example, a parent thinks when his son brings him his grades – four Bs and the rest excellent – “he won’t get very far.” Could it be that the parent was overly demanding?
- Dichotomous thinking. Evaluating one's own qualities by resorting to extreme categories such as good/bad, smart/dumb, etc. For example, a housewife burns her food one day and thinks “I'm a mess.” How many things do you do well/very well?
- Emotional reasoning. Assuming that our negative emotions necessarily reflect reality. For example, feeling anxious would be enough for Ramon to think there is danger and become alert. Could it be a perceived danger, not a real one?
- Disqualification of the positive. Rejecting positive experiences for weak reasons. For example, a student – being congratulated by her teacher for her good grades – thinks “I could have done more.” Maybe you're being overly demanding?
- “I should…” statements. Applying rigid rules about our obligations to others. For example, a mother sees her child fall while playing in the park and thinks “I should have done more, I'm a bad mother.” But has the child been hurt?
- Externalization of one's own worth. Minimize our role in what gives us value. For example, a worker is congratulated for having the most sales and thinks “I have been lucky.” But aptitudes and attitudes must have done something, right?
What are the characteristics of negative thoughts?
As we have said before, they are a type of automatic thoughts that usually start with should/must, would have to/have to… and include absolute terms such as: never, always, everything, nobody,… with a tendency towards dramatization.
An example would be: “I should do everything well, otherwise I will always be useless.”
How can you identify negative thoughts?
Thoughts are nothing more than hypotheses that we make based on what we have experienced or learned, but which determine our emotions and behaviors and we become so accustomed to them that we do not question them.
Through eThe use of cognitive behavioral therapywe can learn to think in a more rational way, that is, in a way that helps us. Thus, therapy will help us “filter” our thoughts to keep the rational and positive ones.
According to this, every thought must meet four criteria of rationality, that is, four rules such that if a thought does not meet any of them, it will be irrational and will have to be reformulated. These criteria of rationality are:
- Objectivity. Based on objective evidence.
- Intensity of emotion. It produces a controlled emotion in the person.
- Utility. It serves to achieve personal goals.
- Formal. It is formulated with flexible words.
The sum of all of them produces rational thought.
How can I detect that I have irrational thoughts?
Tracking concerns through various vital areas. To do this, we will use the example of the irrational thoughts that Elia had when she came to the consultation.
- Familiar “I am unable to tell my father what I think”
- Social (General and friendships) “I need the approval of others”, “I don’t know how to take care of relationships”
- Studies/work “I should have moved more and tried other things”
- Staff “I have spent many years without making decisions, without enjoying myself”
- Couple/Sentimental “Nobody will love me”
- Health “I wake up in the morning and I don’t feel like doing anything”
- Future/past “How did I get to this point?” “I have no way out.”
How can it become a vicious circle?
Because automatic, negative and irrational thoughts such as: personal and social negativism, catastrophic or rigid thinking, feelings of guilt, inferiority and pessimism,… become emotions through activating factors of these thoughts that are usually stressful life events, whether biological, psychological or social, belonging to the past or the present (even referring to the future).
In this way, we get emotions such as sadness, guilt, anxiety, hopelessness, plus somatic symptoms such as headaches, abdominal and muscle pain, sleep and appetite disorders, and concentration problems. Finally, all of this causes altered behavior in the form of loss of interest in things, reduction of pleasurable activities, social isolation, suicidal and thanatolytic behavior.
How can you work with negative thoughts in therapy?
Learning to identify them involves a process similar to learning any skill. Some patients and therapists pick up on them quickly and easily, while for others it may be more difficult and require support with words or images.
In any case, work is done on AP (automatic thoughts) if the therapist observes a change in the patient's mood throughout the session, which can be seen through the «clues» – both verbal and non-verbal – that the patient himself gives throughout the psychotherapy session and which, therefore, is linked to an increase or decrease in certain emotions. All of this can refer to the patient himself, to the therapist – or, better said, to the patient's perception of the therapist's reactions – or even to the topic or topics that are being discussed during the session. In any case, a set of emotions are brought together, which are difficult to find elsewhere, which make up very affective thoughts – whether positive or negative – and which constitute the most important elements to work on.
Likewise, we work with all those ideas that may interfere with the patient's motivation or self-esteem, concentration and relaxation during and in the therapeutic relationship. For all these reasons, it is important to identify the APs when they occur, because it gives the patient the opportunity to control them and react to them.
The modification of the PA in session is done through different techniques, the most important being cognitive restructuring.
There are more important aspects to highlight
Certain terms must be correctly differentiated to avoid misunderstandings. Thus:
- Differences between PA and interpretations or perceptions. What happens in therapy is that, many times, patients do not refer to a true AP but to a perception of it; for example, «they will laugh at me» is a perception or interpretation, perhaps it does not happen like that, because the true AP must be «I do not like myself»
- We must distinguish between the most useful and the least useful PAs. Some of the PAs are irrelevant to the problem at hand. Thus, if Elia – the protagonist of our initial case – tells us “I don't like the…