Checking thoughts during activity

Cognitive behavioural therapy is all about learning the relationship between thoughts, emotions and actions – and the latter part is probably the bit that interests me the most! People differ in the ease with which they can access their own thoughts, but one way to elicit ‘things that are going through the mind’ is to ask the person to participate in an activity that you think may trigger an emotional response from them. This is particularly helpful when you’re looking to identify a situation in which anxiety or fear prevents the individual from being able to participate in ‘normal’ activities because of their beliefs about pain.

Remembering that many of us find it difficult to actually recall an experience, being in context can be really helpful for generating initial ‘automatic thoughts’. This can be called a ‘behavioural approach test’ (often used in exposure therapy for phobia – this is where the individual and the feared stimulus are brought into some degree of proximity so the person can learn to master the anxiety associated with the stimulus) – but in this case, it’s more like ensuring the cues that are around in everyday life are present so that the person we’re working with has easier access to their thoughts – emotions – and actions.

In our everyday practice, as therapists we ask people with pain to do things that are challenging – physiotherapists may ask the person to do an exercise that increases pain, occupational therapists may ask the person to make the bed or sit at a computer that the person has reported they have trouble with – and the response can often be ‘no way!’. It’s at this point we can intervene by asking the person some simple questions to draw out their automatic thoughts:

• ‘What’s going on for you right now?’
• ‘What are you thinking right now?’
• ‘What’s going through your mind?’
• ‘What do you think will happen if you go ahead?’

Some people don’t think in sentences, and instead there will be an image – perhaps of themselves falling over while doing the exercise, or of them getting ‘stuck’ while bending forward to make the bed. You may like to ask ‘is there a picture in your mind of what might happen?’

Now it’s at this point that many of our clients will say ‘it hurts’, ‘it’s going to hurt’ – and this can sometimes be true! So it’s not that the thought itself is inaccurate, it’s more a case of whether the thought is helpful or unhelpful, or it may instead be the thought or meaning that underlies the automatic thought. Other thoughts may be inaccurate, in which case it’s more helpful to ask the person to consider the likelihood of this happening, and suggest perhaps a more realistic appraisal.

Some of our clients won’t identify a thought – they’ll be clear that it’s a ‘feeling’. In CBT terms, emotions are preceded by cognitions (although I would hazard a bet that there is a reciprocal relationship in many cases), so the work is to identify what that emotion is about – why are you feeling ‘angry’, or ‘frustrated’, or ‘fearful’? Even identifying the specific emotion is quite hard work for some people who may not be able to give a word to describe their emotions (this is alexithymia). In this situation, depending on the purpose of your session, you may like to work through several words until your client can agree on the type of emotion, and then you’ll need to return to the underlying thought that generated the feeling.

What we’re trying to do here is understand the belief that the person has about doing this activity.

When someone says ‘it’ll hurt’, or ‘my pain will get worse’ what are they actually saying? The unspoken message might be ‘and I shouldn’t feel this pain’, or ‘if I do this and increase my pain it will mean I will get really irritable by the end of the day’, or ‘this pain might mean there’s something that hasn’t healed yet’.

Each of these unspoken thoughts represent beliefs or attitudes or rules that generate concern and often lead to avoiding the activity. While it’s not always important to directly address thoughts (behavioural approaches work without directly addressing thoughts!), it can be helpful especially if the belief, attitude or rule is compromising the person’s readiness to attempt other activities.

How can you tell someone’s having an unhelpful automatic thought?

Wonder what was going through his mind?

Often it’s a subtle shift in posture, body language, perhaps breathing rate or increased arousal (increase in muscle tone, sweating etc) that shows that this person is accessing an automatic thought that is generating an emotion. Sometime’s it’s overt – the person says ‘I won’t be doing that!’ Sometimes its a change in emotional tone (tears perhaps, or irritation), and sometimes its a pause during which the person isn’t completely attending to you.

Why would we want to work with thoughts?

Well, as I’ve said above, it’s not always essential to directly address thoughts if you’re using an effective behavioural programme. Other times these thoughts become quite unhelpful and prevent the person from engaging in your therapy. It can prevent them from adopting new skills (eg using pacing or even maintaining activity despite pain), or mean that they ‘resist’ therapy because something you’re asking them to do generates uneasiness.

By listening carefully to the meaning of what the person is saying, it’s possible to increase the level of rapport between you and the client, demonstrate your level of understanding and acceptance of them, and help them directly learn about their beliefs. This can be a powerful way for them to start becoming aware of what might be maintaining disability or avoidance – and helps you help them to consider both the good things about their beliefs, and the not so good things. Then they are able to make informed choices, which is really what we as therapists help people do.