Cognitive distortions or ‘unhelpful thinking styles’ are ways that our thoughts can become biased. As conscious beings we are always interpreting the world around us, trying to make sense of what is happening. Sometimes our brains take ‘short cuts’ and generate results that are not completely accurate. Different cognitive short cuts result in different kinds of bias or distortions in our thinking. Sometimes we might jump to the worst possible conclusion, at other times we might blame ourselves for things that are not our fault. Cognitive distortions happen automatically – we don’t mean to think inaccurately – but unless we learn to notice them they can have powerful yet invisible effects upon our moods and our lives. Cognitive distortions were first noted by Aaron Beck in his research with depressed patients in the 1960’s . They formed a central part of his cognitive theory of depression  and, later, cognitive behavioral therapy (CBT).
A good example of a cognitive distortion is what Beck originally called ‘selective abstraction’ but which is often now referred to as a ‘mental filter’. It describes our tendency to focus on one detail, often taken out of context, and ignore other more important parts of an experience. For example, Jenny delivered some teaching at her workplace and got a round of applause at the end as well as numerous colleagues telling her how well she did and how helpful they had found her presentation. When she looked at the feedback forms afterwards she noticed one form with critical comments and a poor rating. She couldn’t stop thinking about this one piece of negative feedback and criticized herself saying “I’m such a rubbish teacher”. As a result she felt awful. Jenny’s thinking process was distorted because she had managed to ignore all of the positive feedback she had received and focus solely on the negative. She did this automatically and without realizing she had done it.
Cognitive distortions are common, entirely normal, and not our fault. None of us are 100% logical and rational like Mr Spock. But when unhelpful thinking styles are present in our lives to an excessive degree they are associated with poor mental health [3,4]. There is strong evidence that people with depression and anxiety think in characteristically biased and unhelpful ways . Recognizing and then overcoming our unhelpful thinking styles is frequently an important part of CBT treatment for anxiety and depression.
How Beck identified cognitive distortions
Cognitive distortions in the context of cognitive behavioral therapy (CBT) were first described by Aaron Beck in his 1963 paper ‘Thinking and depression: 1. Idiosyncratic content and cognitive distortions’ . Beck was a psychiatrist who had also trained in psychoanalysis. In the 1960’s he was conducting research into the treatment of depression. Part of Beck’s research in a psychiatric clinic involved conducting interviews with depressed patients whom he was seeing for psychotherapy. The interviews were conducted when the patients were moderately to severely depressed. The patients were encouraged to free associate (talk freely) and Beck’s policy was to intervene only minimally, taking notes as his patients spoke. Some patients also kept notes of their feelings and thoughts between sessions which Beck used as additional data.
When Beck examined what his patients had told him he noticed themes in the cognitive content of the depressed patients and noted that:
“A crucial characteristic of the cognitions with this content was that they represented varying degrees of distortion of reality. While some degree of inaccuracy and inconsistency would be expected in the cognitions of any individual, the distinguishing characteristic of the depressed patients was that they showed a systematic error; viz, a bias against themselves.”
Beck noted that distortions were particularly likely to be present when the situations (cues) are ambiguous. Using a computational metaphor Beck described what he was observing in his patients as ‘faulty information processing’:
“He [the depressed patient] tends to perceive his present, future, and the outside world (the cognitive triad) in a negative way and consequently shows a biased interpretation of his experiences, negative expectancies as to the probable success of anything he undertakes, and a massive amount of self-criticism”.
Beck’s cognitive distortions
Beck included five cognitive distortions in his original list published in 1963 , and added an additional two in Cognitive Therapy of Depression which was published in 1979 . Beck’s cognitive distortions included:
Arbitrary interpretation / arbitrary inference
Arbitrary inference is “the process of forming an interpretation of a situation, event, or experience when there is no factual evidence to support the conclusion or where the conclusion is contrary to the evidence” .
Example: As John walked down the street he thought to himself “Everyone can tell that I’m a loser”. This thought is distorted for a number of reasons: John has no way of knowing what ‘everyone’ thinks, and it is extremely unlikely that anybody is even thinking about him since most people are likely to be wrapped up in their own concerns just as he is.
Selective abstraction is “the process of focusing on a detail taken out of context, ignoring other more salient features of the situation, and conceptualizing the whole experience on the basis of this element” .
Example of selective abstraction: Jenny delivered some teaching at her workplace and got a round of applause at the end as well as numerous people saying how well she did and how helpful they had found her presentation. When she looked at the feedback forms she noticed one form with critical comments and a poor rating. She couldn’t stop thinking about this feedback and criticised herself saying “I’m such a rubbish teacher”. Jenny’s thinking is distorted in this case because she has automatically focused on the one negative piece of feedback to the exclusion of all the positive feedback – her judgement of her teaching was not a fair reflection of the evidence.
Overgeneralization is the process of “drawing a general conclusion about their ability, performance, or worth on the basis of a single incident” .
Example of overgeneralization: Carl gets a C- on a piece of homework, thinks to himself “I’m going to fail everything”, and feels hopeless. Carl’s thinking is distorted in this case because the conclusion he is reaching is too broad given the evidence. It is equally plausible that his c-minus is a ‘blip’ and that he will do well on tests in the future, or that there were good reasons why he got a poor grade this time that could be remedied in the future.
Magnification and minimization
Magnification and minimization are “errors in evaluation which are so gross as to constitute distortions” .
Example of magnification: Paul’s baby is sick on his only clean shirt before he has to go to work to give a presentation. He has an image of his boss noticing, giving him a disgusted look, and firing him on the spot. Paul’s thinking (an image in this case) is an example of magnification because he is imagining and paying attention to a worst-case scenario.
Example of minimization: Emma’s friend was the third person to try to tell her that she thought Emma was drinking too much and putting herself in danger. Emma dismissed her concerns by saying “You’re like everyone else, you worry too much” and thought to herself “I don’t know what they’re all so worried about”.
Inexact labeling is where “the affective reaction is proportional to the descriptive labelling of the event rather than to the actual intensity of a traumatic situation” . When we apply labels to others we can feel frustrated, when we apply them to ourselves we can feel depressed.
Example of labeling: Someone bumps into Sally as she gets off the train. Sally calls the person a “complete f****** idiot” and feels furious. Her conclusion that the person who bumped her is a ‘complete idiot’ is a distortion because it is such an extreme interpretation of what happened. A more benign (and realistic) interpretation is that the other person was simply clumsy or made a mistake.
Personalization describes “the patient’s proclivity to relate external events to himself when there is no basis for making such a connection” .
Example of personalization: On Sam’s journey to work he steps in a puddle, realizes he has forgotten his watch, and has to rush after his train is late. He thinks “the world has got it in for me” and feels deflated. Naturally Sam has placed himself at the centre of the story (we all tend to be somewhat egocentric), but his thinking is biased because he has assigned agency to the world around him and he is implicitly making the prediction that the world will continue to ‘have it in for him’.
Absolutistic, dichotomous thinking
Absolutistic, dichotomous thinking describes “the tendency to place all experiences in one of two opposite categories; for example, flawless or defective, immaculate or filthy, saint or sinner” .
Example of absolutistic dichotomous thinking: Tanya either did things perfectly or not at all. If she saw the slightest speck of dust at home she saw it as ‘filthy’. She was similarly strict with descriptions of herself – she was either doing ok, or was failing in every way. Her thinking is biased because she fails to see life in the ‘shades of grey’ that it actually operates.
Dr David Burns was an early student of Aaron Beck who has done much to popularize CBT. In his self-help book Feeling Good  he compares unhelpful thinking styles to the kinds of illusions performed by magicians “When you are depressed, you possess the remarkable ability to believe, and to get the people around you to believe, things which have no basis in reality”. Importantly, he used language that made cognitive distortions more engaging and understandable. Burns’ unhelpful thinking styles include:
Burns describes all-or-nothing thinking as the “tendency to evaluate your personal qualities in extreme, black-or-white categories” . He argues that absolutes rarely exist in our universe, and that evaluating ourselves according to absolute categories or criteria is unrealistic because life simply does not work that way.
Burn’s describes overgeneralization as the process of arbitrarily concluding that “one thing that happened to you once will occur over and over again” . Further, he argues that overgeneralization is almost entirely responsible for the pain of rejection and gives the example of being turned down on a date morphing into the conclusion “I’ll be lonely and miserable all my life”.
The mental filter is described by Burns as the process of picking out a negative detail in any situation and dwelling on it exclusively, thereby perceiving the whole situation as negative. Burns introduces the metaphor of a pair of eyeglasses with special lenses that filter out anything positive: no positive information is allowed through the filter and so you naturally draw the conclusion that everything is negative.
Disqualifying the positive
Burns describes the ability to transform neutral or even positive experiences into negative ones as a “spectacular mental illusion” . Instead of just filtering out or ignoring positive information when it occurs it is dismissed as a ‘fluke’, or argued against (“that doesn’t count”). Burns gives the commonplace example that many of us engage in of disqualifying compliments by telling ourselves “they are just being nice” but also gives more extreme examples common in people suffering from depression .
Jumping to conclusions (mind reading, the fortune teller error)
In Feeling Good Burns describes jumping to conclusions as the process of “arbitrarily jumping to a negative conclusion that is not justified by the facts”. With the ‘mind reading’ variant we assume that other people are thinking negatively about us. With the ‘fortune telling’ variant we imagine and predict that bad things are going to happen to us. In neither case are the conclusions that we draw supported by the evidence . To some extent these are natural processes – who hasn’t had the experience of thinking that a disaster has befallen a loved one who is late home from work? But taken to extremes, as is often the case in depression and anxiety, these can be extremely destructive biases.
Magnification & minimization
Magnification and minimization are described by Burns as the ‘binocular trick’ because of the way that errors, fears, or imperfections are exaggerated while strengths and achievements are made to seem small and unimportant. Again, Burns emphasises that this unhelpful thinking style is an involuntary habit “the problem isn’t you – it’s the crazy lenses you’re wearing!” .
The unhelpful thinking style of emotional reasoning is where emotions are taken as evidence of truth. Burns argues that this is backwards because your feelings reflect [are a product of] your thoughts and beliefs, and invalid because if thoughts are biased then emotions experienced as result don’t correspond to the world as it is . Examples of emotional reasoning include feeling hopeless and concluding that a problem is impossible to solve, or feeling angry and concluding that another person is acting badly.
Albert Ellis described the attempts to motivate ourselves by saying “I should do this” or “I must do that” as ‘musturbation’. Burns argues that attempting to motivate ourselves in this way can, paradoxically, lead to apathetic and unmotivated feelings. Feelings of frustration are often the result of directing should statements towards others. Feelings of shame, guilt, and self-loathing are often the result when should statements are directed at ourselves.
Labeling and mislabeling
Burns argues that labeling – the process of saying to ourselves “I am a [label]” – is an extreme form of overgeneralization . “I am stupid”, “I am ugly”, “I am hopeless” are all negative labels. Burns argues that labels are biased because human are fundamentally too complex to sum up by using such a simple descriptor.
Personalization and blame
Personalization is the unhelpful thinking style whereby “You assume responsibility for a negative even when there is no basis for doing so. You arbitrarily conclude that what happened was your fault or reflects your inadequacy, even when you were not responsible for it” . Burns argues that personalization leads to inappropriate guilt, but his examples are equally consistent with strong experiences of shame. In a nice description of one component of the bias he describes how “you have confused influence with control over others”.
Other unhelpful thinking styles
As well as the cognitive distortions described by Beck and Burns many other cognitive biases have been identified by researchers. Cognitive biases are ways in which human thinking is not 100% accurate or is systematically subject to errors. Rachman and Shafran  describe cognitive bias as “a particular style of thinking that is consistent, non-veridical, and skewed”. Some examples of other cognitive biases include:
- The ‘availability heuristic’ which describes our tendency to overestimate the likelihood of events with greater ‘availability’ in memory (i.e. ones which we remember better).
- The ‘confirmation bias’ which is the tendency to search for, interpret, focus on, and remember information which is consistent with our preconceptions.
- The ‘Dunning-Kreuger effect’ which describes tendency for unskilled individuals to overestimate their own ability and the tendency for experts to underestimate their own ability.
- ‘Stereotyping’ which describes how we expect a member of a group to have certain characteristics without having actual information about that individual.
The number of ways that human thinking can be biased is very large (Wikipedia keeps an exhaustive list of cognitive biases) and although any could conceivably be affecting clients seeking therapy only a minority have traditionally been considered to be relevant to CBT practitioners. Some of the most important cognitive distortions that are frequently relevant to clinicians are outlined here.
Rachman & Shafran  describe how ‘thought-action fusion’ (TAF) was first encountered when working with clients with obsessive compulsive disorder (OCD) experiencing pure obsessions. TAF refers to the “belief that (one’s) specific intrusive thoughts can directly influence the relevant external event and/or the belief that having these intrusive thoughts is morally equivalent to carrying out a prohibited action”. Two subtypes of thought-action fusion are probability TAF in which there is a belief that having the intrusive thought increases the probability of the unwanted event occurring, and morality TAF whereby there is a belief that having the intrusive thought is morally equivalent to actually carrying out the prohibited act. An example of probability thought-action fusion would be having an intrusive sexual thought and believing that unless the thought is ‘pushed away’ the sexual act is likely to take place. An example of morality TAF would be believing oneself to be flawed for having the intrusive sexual thought in the first place.
Rachman and Shafran give the example of the TAF bias in a patient with OCD who dreaded going to bed because he feared that we would die in his sleep. He rated the probability of this happening highly (10-20% per night) and reported that his belief was high because he experienced the unwanted thought that he would die in his sleep. He believed that other people who did not share similar thoughts were at much lower risk of dying in their sleep. His TAF represents a bias because there is no actual link between dying in one’s sleep and thoughts of it occurring. His bias meant that he had managed to ignore all of the many occasions where he had thought of dying in his sleep and yet had not died.
Paul Gilbert  argues that although ‘disqualifying others’ is not commonly noted as a cognitive distortion, clinicians will often recognize their patients responding to a genuinely kind or approving comment with the idea “You are only saying that to make me feel better”. He argues that patients disqualify positive things said to them because they may believe that either the other person is deceiving them (distrusting), or that if the person really got to know them then they would not be so approving (shame-prone). Gilbert proposes that this distorted form of reasoning is the result of a highly-sensitive ‘deception detection’ system which operates in a ‘better safe than sorry’ manner. When this bias is present to a substantial level it reduces the amount of soothing and reassurance that an individual is able to receive from those around them, perpetuating their distrust and experience of shame.
Hindsight bias is the tendency to perceive that something was foreseeable when it was not. Many survivors of trauma experience hindsight bias. It is common for therapists working with traumatized individuals hear “If only I hadn’t gone with him that night [it would not have happened]”, “If only I had taken a different train”, or “It was obvious, I should have known better”. One common result of hindsight bias is that survivors of trauma blame themselves for outcomes that were not their fault. The hindsight bias often becomes evident to client when therapists use Socratic questioning to explore the client’s knowledge and decisions at the time of the trauma:
Therapist: Could we explore this idea that you are responsible for being attacked because you got into the attacker’s car voluntarily?
Therapist: Did you have any idea of his actual intentions when he offered to drive you home that night?
Client: No, he was often the designated driver and he had taken many of us home safely before.
Therapist: And that night was no different?
Client: I didn’t have any reason to think so. We had all had a nice time that night and I didn’t have any reason to think differently.
Therapist: When was it that you realized you should not have got into his car?
Client: When he attacked me.
Therapist: So how could you have known not to get into his car when you got into his car?
Client: I guess I couldn’t have known.
Some clinicians have argued that hindsight bias has the emotionally positive effect of making unwanted events seem foreseeable. The thinking goes something like this: “If bad events are foreseeable and I just missed it that time, then as long as I am vigilant I will be able to spot bad events in the future”. Thinking in this way can be reassuring because it makes us feel that we are in control of whether or not bad things happen to us. However, it is biased because it fails to reflect the sad truths that some traumas are not foreseeable and that sometimes bad things happen to good people.
Comparing ourselves to other people is not inherently biased – all of us make accurate social comparisons such as “I’m taller than him”, or “She’s from a different social background to me”. However, Paul Gilbert notes that comparing ourselves unfavourably with others has been linked to many forms of personal difficulty including depression, envy and jealousy . He proposes that we have an evolved propensity to make social comparisons and that although it may be possible to examine social comparisons for their rationality once they have occurred, it may be difficult to stop them from occurring in the first place. Interestingly, he notes that social comparison can be adaptive, citing Baumeister and colleagues  who suggest that “High self-esteem people socially compare to draw attention to their talents and abilities, while low self-esteem people opt for damage limitation, self-protection, and minimizing exposure of their weak points”. The clinical implication of these observations is that we can train our clients to notice the kinds of social comparisons that they are making automatically and to get used to noticing any patterns of biases in our social comparisons: for example to notice whether we always compare ourselves unfavourably. Techniques such as mindfulness or cognitive defusion can be helpful for ‘unhooking’ from these automatic social comparisons – we can improve our mood by noticing them for what they are (automatic unhelpful thoughts) rather than ‘truths about ourselves’.
Self-blame (when things are not our fault)
In a similar manner to how social comparison is not necessarily harmful, blaming ourselves is not prima-facie a cognitive bias. However, most clinicians will recognize clients who blame themselves for things that could not possibly be their fault. Common examples in trauma therapy include victims of childhood sexual abuse who blame themselves for their abuse (“It was my fault because I didn’t say no” – biased because they ignore the agency of the abuser), or victims of interpersonal violence who say “I brought this on myself” in spite of overwhelming evidence to the contrary. In these instances the self-blame is evidence of a cognitive distortion. Gilbert  makes a strong case for why distorted self-blame may actually be an adaptive response to some circumstances:
- Self-blame may offer some illusion of control. For example that a negative outcome was potentially controllable or avoidable (often seen in trauma patients).
- Self-blame avoids attacks on others. If we allow ourselves to blame others it might lead to a strong desire to retaliate which might also elicit an overpowering counter-attack from others. In circumstances where this might be possible self-blame would be a ‘better safe than sorry’ tactic.
- Self-blame may be a learned response. As a relatively powerless child it may be safer, and elicit less parental anger, to blame ourselves and act submissively. In households with anger-prone parents children may sadly have many opportunities to learn this cognitive style.
Why do we think in unhelpful ways?
So far we have explored common cognitive distortions in CBT, learned how unhelpful thinking styles are apparent in our automatic thoughts, and have learned about the evidence for their impact on people’s mood. But where do unhelpful thinking styles come from? To answer this question we have to learn more about the theory of CBT. According to the cognitive model there are different levels of cognition:
Figure: Levels of cognition specified in the cognitive model are: Core beliefs; Intermediate beliefs (rules, attitudes, assumptions); Automatic thoughts.
Core beliefs are a fundamental level of belief. Judith Beck characterizes them as “global, rigid, and overgeneralized” . Automatic thoughts are specific to the situation in which they are generated. Assumptions, attitudes, and rules are an intermediate level of belief which develops as the individual tries to make sense of the world around them. The cognitive model suggests that the particular kinds of automatic thoughts to which we are prone are a result of the core and intermediate beliefs that we hold. Or to put it another way: if our automatic thoughts are biased, then these biases are driven by our beliefs and assumptions. You can think of automatic thoughts as the plants that grow: which plants grow will depend on the kind of soil that we give them. To give some clinical examples:
David had grown up in a household where his parents were very critical and placed great emphasis on academic achievement. His brother did well academically but David always struggled to meet his parent’s high standards. He has developed the core belief “I’m useless” and the (protective) assumption “As long as I achieve I am ok”. When he fails a test he has the automatic thought “I’m a complete failure” characterized by the ‘dichotomous thinking’ error.
Rochelle experienced a lot of abuse as a child. Her parents were neglectful, she was abused by a relative, and she was bullied throughout her school career. She held the beliefs “I am unlovable” and “People will only ever hurt me”. She was quick to assume that others were likely to harm her, felt anxious, and struggled to form meaningful relationships. In therapy an examination of her automatic thoughts revealed lots of catastrophizing. Discussing some of the assumptions that she held Rochelle said that she always assumed the worst because that was what life had typically given her. Rochelle’s example is interesting because her catastrophizing bias was potentially adaptive during her dangerous childhood, but may be less helpful for her as an adult.
A fascinating insight from Beck’s Cognitive Therapy of Depression is that each cognitive error is driven by specific assumptions . If it is our automatic thoughts that are biased, then the biases are driven by our beliefs and assumptions: “Patient’s cognitive errors are derived from some type of assumption”. Table 1 gives some examples of cognitive errors and the associated assumptions:
|Assuming temporal causality (predicting without sufficient evidence) / Jumping to conclusions||If it has been true in the past then it’s always going to be true.|
|Catastrophizing||Always think the worst, it’s most likely to happen to you.|
|Dichotomous thinking / Black and white thinking||Everything is either one extreme or the other.|
|Excessive responsibility / Personalization||I’m responsible for all bad things, failures, etc.|
|Hindsight bias||All (bad) events are foreseeable. Understanding right now the chain of events that led to a (bad) outcome means that the event was foreseeable at the time.|
|Labelling||It is possible and fair to sum up an entire human being and their life in one word.|
|Overgeneralizing||If it’s true in one case it applies to any case which is even slightly similar.|
|Selective abstraction / mental filter||The only events that matter are failures. I should measure myself by my errors.|
|Thought-action fusion||Having a thought increases the chances of that event happening (probability TAF). Having a thought is morally equivalent to carrying out that act (morality TAF).|
Table 1: Unhelpful thinking styles (cognitive distortions) and associated assumptions.
“Why do we think in unhelpful ways?” part two: an evolutionary view
The ability for humans to think in abstract ways is the product of evolution. We have brains that allow us to think about things other than the here-and-now because that ability has benefited the survival of our species. One implication of this insight is that thinking itself is likely to have been optimized for survival rather than accuracy. Paul Gilbert published a fascinating evolutionary take on cognitive distortions in 1998 . In it he reviews developmental explanations for cognitive distortions including the psychoanalytic approach viewing distortions as “resulting from unconscious motivations and conflicts originating in childhood” and the cognitive approach whereby cognitive distortions are “schema-driven reasoning errors” originating in belief structures laid down in childhood.
Gilbert proposes that an evolutionary explanation does not necessarily conflict with developmental explanations but can exist as a complementary view. A summary of his argument is that:
- Humans often reason on the basis of heuristics rather than logic (i.e. we have fast and slow thinking )
- The heuristics that humans use are probably the result of natural selection (12)
- It follows that “Although some forms of reasoning may lead to distress and appear as cognitive distortions this does not necessarily mean they reflect errors in processing as such but rather the activation of evolved (previously) adaptive heuristics and algorithms.” 
Gilbert goes on to argue that “Although cognitive therapists stress the importance of rational decision making, and the importance of testing the evidence, evolution has only enabled rationality to emerge in so far as it aids survival and inclusive fitness” . He proposes that animals have evolved a ‘better safe than sorry’ threat detection system which has a tendency to assume the worst and that information processing has therefore evolved to minimize the cost of mistakes, but not mistakes themselves. In his view information processing is inherently biased in the service of helping us to stay alive. The implication of this line of thinking is that some of the common unhelpful thinking styles may confer an evolutionary advantage. Consider the following biases:
Jumping to conclusions
For a speed advantage it may be helpful to think categorically “Is the threat present or not?”. According to this account jumping to conclusions is typical of a ‘better safe than sorry’ mode of thinking. This bias is likely to occur in pressurized situations when emotions are running hot or where time is of the essence.
All or nothing thinking
Gilbert argues that this is a categorical (yes/no) way of thinking that is therefore a quick way of evaluating a situation. Speed can confer a survival advantage which explains why this error occurs. This bias is especially likely to persist in situations where time is of the essence.
Gilbert argues “the reliance on feelings as sources of information to guide behaviour has long been part of our adapted behaviour” . This is the genesis of Gilbert’s “tricky brain’ idea in compassion focused therapy (CFT): “Hence when we explore emotional reasoning with patients, we can recognize that they are encountering the urgencies of our more primitive brains – and thus the enormous struggle they sometimes have to bring these dictates under rational control”.
Disqualifying the positive
This can be related to modesty, which, at low levels, is seen as an attractive trait. It may also be a ‘better safe than sorry strategy’ because “in the absence of clear signals of success … it may be riskier to assume one can do something rather than assume one can’t”. Driscoll  argues that it may be adaptive by reducing the expectations of others, avoiding envious attacks from others, or by personally drawing attention to one’s inadequacies one may avoid attacks from others.
This evolutionary approach to cognitive distortions has interesting clinical implications for cognitive behavioral therapists working with clients who think in unhelpful ways. Gilbert’s ideas have since developed into the distinct therapeutic approach of Compassion Focused Therapy (CFT). In CFT cognitive distortions are not necessarily combated directly. Instead, what CFT brings is a layer of scientifically-grounded understanding to thoughts. Therapists might articulate the idea “No wonder you think this way – you have a tricky brain which is designed for survival instead of happiness”. Instead of direct restructuring the approach helps clients to soften their attitude towards themselves and reduces personal responsibility by viewing them as a product of an evolved brain (which it is not your fault for having). Clinicians interested in helping clients to foster self-compassion are advised to read further regarding the Compassion Focused Therapy (CFT) approach.
Thinking in a balanced way: treatment of unhelpful thinking styles with CBT
Helping clients to think in a more balanced fashion is a core component of traditional cognitive therapy. Clinicians may need to move clients through a number of stages in order to effectively help them to overcome unhelpful and habitual cognitive biases.
Help your clients understand about automatic thoughts
Your clients need to understand that everybody experiences automatic thoughts and images. Essential information to impart is that automatic thoughts are involuntary cognitions which can be triggered by external stimuli in the world around us, or by internal stimuli consisting of our own emotions, body sensations, and other cognitive content (thoughts, images, memories, urges). Automatic thoughts are often highly believable, and if believed or allowed to pass unchallenged they can have a profound and detrimental effect upon our emotional state.
Train your clients to catch their automatic thoughts using thought records
Traditional cognitive therapy is interested in our cognitive content. This means that your clients need to know what thoughts and images are going through their minds if they are to be able to balance their thinking. Thought records are a brilliant way of catching our automatic thoughts. Clients are encouraged to complete thought records whenever they notice a significant change in how they are feeling – this is a strong clue that they have had an automatic thought. At their simplest, thought records consist of a form with space to record information about the situation in which a thought occurred, the thought or image itself, and how it made them feel. Clients are encouraged to record their thoughts and images as close as possible to the time they occurred as that way the recorded information is likely to be as detailed as possible.
Understand and notice cognitive biases
Understanding about unhelpful thinking styles can be extremely normalizing and destigmatizing. Many clients like to see handouts of cognitive biases. As a clinician it can be helpful to ask “Do you recognize yourself in any of these biases?” – clients will frequently identify with many (sometimes all) of the common cognitive biases. Judicious therapist use of self-disclosure can be helpful when working with reticent or shame-prone clients.
To help your clients learn to recognize unhelpful thinking styles in their daily life you can use the Dysfunctional Thought Record. This thought record has columns for recording standard information about situations, thoughts, and emotions, but also contains prompts to help clients practice identifying the biases present in their thoughts.
Cognitive restructuring, or challenging the content of our negative automatic thoughts is a mainstay of CBT. We discuss the process of challenging our negative automatic thoughts extensively elsewhere, but clinicians should be aware of the wide variety of techniques available to them including:
- Traditional disputation. The traditional disputation method of cognitive restructuring involves examining the evidence for and against a thought. Clients often find it easy to generate reasons why a thought is true, but may initially need assistance to consider reasons why a particular thought might not be 100% true all of the time. Once evidence for and against an automatic thought has been generated clients can be asked to write a balanced thought which takes into account all of the collected evidence.
- Court-trial style disputation. Some clients find it helpful to view the disputation process using the metaphor of a court trial. The automatic thought is put ‘in the dock’. The job of a defence lawyer is to argue that the thought is true while the job of the prosecution is to argue that it is false. A jury weighs the evidence and the judge reads a verdict: a considered alternative which takes into account all of the evidence.
- Compassionate cognitive restructuring. Cognitive restructuring can be completed in a compassionate framework by: examining the negative thought through a compassionate lens, activating the self-other compassion system by considering the perspective of what you would say to others in a similar situation, and activating the other-self compassion system by thinking about what a compassionate other would say to you.
Making the restructured thinking habitual
One favoured approach amongst expert practitioners is to intervene with fewer techniques but to ensure that clients benefit maximally from each. It is often helpful for clients to ‘overlearn’ the habit of noticing their automatic thoughts and restructuring their negative automatic thinking. Once clients have had sufficient practice using paper-and-pencil thought records it is worthwhile to encourage them go through the disputation practice in their head. Many clients report that it soon becomes second-nature to them to notice automatic thoughts and to ask themselves “What is the evidence for believing that this thought is true?”.
Once symptoms have (at least partially) remitted shift to targeting assumptions
Each cognitive distortion is underpinned by assumptions specific to that distortion. For example, catastrophizing is underpinned by the assumptions “always think the worst” and “the worst is likely to happen to you”, and hindsight bias is underpinned by the assumption “understanding right now the chain of events that led to a (bad) outcome means that the event was foreseeable at the time”. Beck and colleagues argue that if clients hold dysfunctional assumptions like these, they are more prone to thinking in a distorted manner . The clinical implication is that working to make these assumptions ‘visible’ and then to challenge them makes clients more resilient and less prone to the recurrence of difficulties. Beck and colleagues suggest a variety of techniques for working effectively with assumptions including:
- Listing the advantages vs. disadvantages of the assumptions
- Acting against the assumption
- Playing “devil’s advocate” and having the client supply counterarguments
- Examining the long-term vs. short-term utility of the assumptions
Consider using cognitive bias modification
Cognitive bias modification is a relatively recent approach with only preliminary supporting evidence. Nevertheless it is a potentially interesting method for working with unhelpful thinking styles. The theory behind cognitive bias modification is that vulnerability to anxiety is driven by selective information processing. For example in cognitive testing, anxious individuals reliably demonstrate an attentional bias towards negative information (attentional bias), and when presented with ambiguous stimuli are more likely to interpret them with negative meanings (interpretive bias). Whereas traditional cognitive restructuring works with distorted thoughts once they have arisen, cognitive bias modification is “designed to change the cognitive processes that give rise to such thinking” . This is accomplished through repeated computer-based tasks which operate to retrain how an individual interprets ambiguous stimuli. There is some evidence that interpretive bias modification (CBM-I) can lead to reductions in anxiety sensitivity and trait anxiety in analogue populations  and hope that this will translate into tangible clinical benefits.
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