Thought Records in CBT
Thought records, also known as ‘examining the evidence’, is a very commonly use clinical tool for tackling negative thoughts. Thought records are often used by clinicians and therapists who ascribed to a cognitive behavioural therapy (CBT) type of orientation.
Patients often present with thinking errors (ways of thinking that are somewhat exaggerated in a negative light), which affects and maintains their psychological problems. Cognitive errors could include personalizing (making bad things that happen about them) and mind reading (believing that others have negative thoughts about them). For example, a person might think that their mother being sad is because they are a failure (personalizing) or think that others believe he is boring (mind-reading).
Thought records are an excellent tool to ‘restructure’ our negative thoughts by factually evaluating the truths and falsities of these negative thoughts. In doing so, we reduce the intensity of a negative thought that creates distressing emotions and come up with a more balanced and reasonable thought that is more accurate to reality.
Below, I discuss how to go through a thought record with a patient and strategies to increase the success of a thought record having a positive effect.
Steps to creating a thought record
Although there are different ways to structure a thought record, I typically use an 8-column approach for a nice step-by-step process to be worked with the patient. Here are the 8 steps discussed in more detail.
1. Situation. Briefly note the situation that elicited the negative thoughts. For example, it could be ‘having an argument with parents’, ‘lying in bed wide awake worrying’, ‘failing an exam’ or ‘thinking about my future’. If the patient has difficulties recalling thoughts, it can be helpful to be more specific in terms of the time, place, and context to jolt memories.
2. Thoughts. Have the patient record what are the ‘automatic thoughts’ they had during the situation. Patients may have several thoughts associated with a situation and it could be about themselves (“I’m a terrible student”), others (“my professor probably thinks I’m a failure”), or the world/future (“I’m not going to be able to get into my dream career”). Focus on doing a thought record for one thought at a time. You can ask “which thought is the strongest for you / resonates with you the most” to determine which thought is the ‘hot thought’.
3. Emotion. The patient can then note the emotions they experienced during the situation along with its intensity from 0 = not at all to 100 = the most I could possibly experience. An example might be anger (90%) or sadness (50%).
4. Cognitive distortion. You and the patient can determine which cognitive distortions or thinking errors may be most relevant at this time. Here’s a list of different thinking errors in depression.
5. Evidence for the thought. There are usually some grains of truth in every thought. In this column, you and the patient honor the truth in the thought and write facts associated with the thought. Remember to ground these statements in fact-based sentences.
6. Evidence against the thought. On the other hand, list some facts that does not support the thought.
7. Balanced thought. At this point, you can get the patient to come up with a balanced thought that properly integrates both the evidence for and against the thought.
8. Re-rate intensity of emotions. Picking up from the emotions written down on column 3, you can get the patient to re-rate their emotions and see if there’s any movement in the intensity of these emotions. Even small reductions can be great!
Here’s an example of what a completed thought record looks like below!
Tips for success with patients
– Take your time introducing different topics. Completing a thought record can require several intermediary, such as noticing the thought and learning about thinking errors. Prior to conducting full thought records, it can be helpful to get patients to start recognizing automatic thoughts and going through different thinking errors.
– Practice makes perfect. It can take a lot of practice to be able to develop balanced thoughts; see improvements in emotions; and use thought records on a day to day in general. Getting the patient to practice using thought records as intersession homework can be a great way to support learning!
– Support finding automatic thoughts. In cases where the patient has difficulty with figuring out what the thoughts were, you can ask patients questions to really get into specifics of the situation. Bring them back to what was going on: who were they with, what were they doing, when and where did this situation occur? By bringing them cognitively back to the situation, they can get a better sense of the emotions and thoughts associated with the situation. Similarly, asking the patient what their emotions were first can be helpful to work towards the automatic thought.
– Target the hot thought. As noted, though records are most beneficial when we target the ‘hot’ thought – the thought that the patient endorses as being very relevant to the situation. You can make a good guess that you’ve arrived at the hot thought when you hear “that’s exactly how I feel” or “that’s the thought that really makes me upset”.
– Make sure the evidence for and against are facts-based. Some patients may provide fairly vague examples or examples that are not grounded in reality (e.g., too positive can be problematic). For a thought record to work well, we want to ensure that the evidence provided are grounded in reality. Especially for evidence against thinking errors, we want examples that are fact-based from the person’s personal history; otherwise, our brain is unlikely to believe it!
– Thought records don’t necessarily work for everybody. This doesn’t mean you’ve done anything wrong. Some people simply don’t resonate with the idea of changing their thoughts. They may prefer a behavioural approach or an emotion-focused strategy instead. One common alternative to thought records can be a more acceptance-based approach to thoughts, such as mindfulness! In mindfulness practice, we seek to accept our thoughts rather than actively change them.
I hope this post was helpful in learning a bit more about how to apply thought records to patients.
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