chapter1

The Cognitive Model

The Cognitive Model

Cognitive behavior therapy is based on the cognitive model of psychopathology, which hypothesizes that people's emotions, body responses, and behaviors are influenced by their perception of events. According to the model, situations do not inherently determine what people feel or how they behave. Rather, it is how people perceive these situations that determine how they react and respond. Therefore, a situation in and of itself cannot cause distress per say. In contrast, it is the interpretation of that situation that drives the distress. A simple schematic of the cognitive model is as follows:

Image summary: A flow diagram showing a sequence of psychological responses. A Situation/Event triggers an Automatic Thought, which then leads to three concurrent outcomes: an Emotional Reaction, a Physiological Reaction, and a Behavioral Reaction. The diagram illustrates how a single event can trigger a multifaceted response through the mediation of a thought.

To better understand the cognitive model, let's put it into practice with a hypothetical example. Imagine that a wedding invitation is sent to a family of three. The dad opens the invitation and thinks, "This is great. I might get to see people I haven't seen in a while. This will be so much fun!" He feels happy and energized, and he puts the date on his calendar.

The mom, on the other hand, thinks, "I don't want to go. I've gained so much weight. People will judge me. I have no energy. I will never be up for this. I cannot go."

She feels down and depressed, her body feels sluggish, and she hides the invitation in the drawer. Their son finds the invitation in the drawer and thinks, "My parents are going to make me go, and this is the worst possible date. I will have to miss the big fraternity rush.

If I don't show up and make a good impression, then I probably won't get an invite to pledge. I'll be the only one of my friends not in Greek life. This is a disaster." He feels anxious, notices his heart pounding as sweat starts to roll down his face, and he starts pacing back and forth trying to come up with the best excuse not to attend.

In this example, the invitation serves as an external trigger, which causes the mom, dad, and son to each have different automatic thoughts about the situation. In turn, they each experience different emotions and body responses, which influence their behavior. However, internal triggers influence our emotions and behaviors as well.

For example, the son may start to focus on his heart rate, shortness of breath, and tingling sensations in his hands. In turn, he may think, “I'm having a heart attack,” and call 911 in a panic. Both internal and external triggers can elicit negative automatic thoughts, which drive distress and problematic behavioral choices.

There are several ways to teach clients the cognitive model and increase their understanding of how thoughts influence their ensuing emotions, body responses, and behaviors. For example, you can take an innocuous situation, such as walking into a coffee shop or handing in an assignment, and help clients consider several possible automatic thoughts that someone might have in each situation. Then, direct them to imagine the potential emotional, physiological, and behavioral reactions that someone might have to that automatic thought.

Alternatively, you can use an example from the client's life, such as a car stopping short in front of them or a situation in which they were running late, and ask them to describe their automatic thoughts about the situation. Then, you can help clients connect how these thoughts are related to their emotional, physiological, and behavioral reactions. You may even wish to add any automatic thoughts and reactions you have personally experienced.

The goal is simply to help clients understand the connection between perception and reaction.

Early in therapy, worksheets can be used to help clients identify their thoughts, feelings, and behaviors in gaining an understanding of the cognitive model. The following pages contain several exercises you can use with your clients to guide them through this process. Whenever possible, it is better to have clients complete these worksheets in session before asking them to try it on their own.

Understanding the Cognitive Model

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According to the cognitive model, for every situation that we experience in life, we have automatic thoughts, which influence how we feel, how our body responds, and how we behave. Here is what the cognitive model looks like:

Image summary: A flow diagram showing a sequence of psychological responses. A Situation/Event triggers an Automatic Thought, which then leads to three concurrent outcomes: Emotion, Physiological Sensation, and Behavior. The diagram illustrates how an individual's internal automatic thoughts mediate the relationship between an external event and their subsequent emotional, physical, and behavioral reactions.

Automatic thoughts are powerful because the manner in which we interpret a situation drives how we react to that situation. For example, let's say that a dog is running toward you on the street (situation/event). If you think to yourself, "That dog is going to bite me!" then you'd probably feel scared (emotion), your heart would start racing (physiological response), and you would probably run away (behavior). However, in the same exact situation, if you were to think, "What a cute dog!" then you might feel happy (emotion), you might smile (physiological sensation), and you might approach the dog to pet it (behavior).

As another example, let's say you are meeting a friend for dinner, who is now 30 minutes late (situation/event). If you think to yourself, "She isn't coming," then you'd probably feel disappointed (emotion), a tear might well up in your eye (physiological sensation), and you might decide to head home (behavior). Alternatively, in the same situation, if you were to think, "She's probably running late as usual or traffic must be horrendous for her to be this late," then you might feel accepting (emotion), relaxed (physiological sensation), and decide to sit at the bar and have a drink until she gets there (behavior).

Therefore, the same exact situation can result in different emotional, physiological, and behavioral reactions—depending on the automatic thoughts that you have about the situation. Let's practice. For the three situations that follow, try interpreting each situation from two different perspectives. For each situation, come up with two different automatic thoughts that someone might have about the situation, as well as the ensuing emotions, body sensations, and behaviors that are associated with that automatic thought.

Situation 1: You text your friend, and two days pass without a response.

Interpretation 1:

Automatic thought: _ _

Emotion: _ _

Physiological sensation(s): _ _

Behavior(s): _ _

Interpretation 2:

Automatic thought: _ _

Emotion: _ _

Physiological sensation(s): _ _

Behavior(s): _ _

Situation 2: Your boss requests a meeting.

Interpretation 1:

Automatic thought: _ _ Interpretation 2:

Automatic thought: _ _

Emotion: _ _

Physiological sensation(s): _ _

Behavior(s): _ _

Situation 3: You arrive home, and multiple unknown cars are in your driveway.

Interpretation 1:

Automatic thought: _ _

Emotion: _ _

Physiological sensation(s): _ _

Behavior(s): _ _

Interpretation 2:

Automatic thought: _ _

Awareness of Thoughts

We constantly experience thoughts throughout the day. Our brains are active all the time, so thoughts constantly pop up or pass through our minds. Most people never think to question their thoughts and just accept them as true. However, our perceptions are not always accurate.

We make errors, and those thinking errors impact our mood, body, and actions. The first step in addressing those thinking errors is simply to become more aware of our thoughts. By paying attention to what we are thinking, we can start to evaluate—and ultimately change—any incorrect or unhelpful thoughts.

The following activity is intended to help you become more conscious and mindful of your thoughts so that you can begin this process.

Sit quietly for the next two minutes. Look around or close your eyes. Try to make yourself aware of the thoughts popping into or passing through your mind. Record what you notice.

Sit quietly for another two minutes. Think back to an upsetting moment. What thoughts are going through your mind?

Sit quietly for another two minutes. Think back to a time that made you happy. Recall the thoughts you had about this situation. The next time that you feel down, try to reflect on this happy memory.

Remind Your Clients:

Thoughts are not always true.

Thoughts are not facts.

Thoughts can be subjective.

Thoughts can be biased by past experiences or by what we hear, read, or see.

Once clients have completed the prior two worksheets in session, have them apply the cognitive model to a personal situation they have experienced in their life. First, ask clients to identify a time when they experienced a strong negative reaction to a situation or event, such as sadness, anger, fear, or any other unpleasant emotion. Then, have clients use the following worksheet to describe the triggering situation, as well as their accompanying thoughts and reactions (e.g., emotions, body responses, behaviors) to that situation. By completing this exercise, clients will learn how their thoughts influence how they feel and behave.

A word of caution: Asking clients to pay attention to distressing thoughts can exacerbate distress! To protect your clients from experiencing unnecessary distress with this exercise, make sure they have a good understanding of the notion that thoughts are not facts. Just because they have a thought does not make it true. Clients must fully embrace this notion before attempting this exercise. In addition, practice this worksheet with your clients together in session before sending them out to explore negative automatic thoughts for homework.

Apply the Cognitive Model: Connect Thoughts and Reactions

As you've learned, your perception of a situation influences your reaction to that situation. In order to help get you into the habit of connecting your automatic thoughts to your reactions, think of a recent situation (either today or in the last several days) when you noticed a shift in your mood or in the way your body felt.

Step 1: Identify the Trigger

Identify the specific trigger that caused you distress. If you're not sure, then think back to what exactly "set you off." That is, think of the prompting event that caused a change in your mood or how your body felt.

For example, if someone canceled plans with you, you don't need to recount the whole story. Rather, just write the specific trigger (e.g., "I received a text from my friend saying that plans were canceled, but I later saw on social media that they were out with other friends.").

_ _

Step 2: Identify the Automatic Thought

When this happened, what went through your mind? That's the automatic thought.

Step 3: Map Your Reaction

Write the emotional, physiological, and behavioral reactions you had in response to this automatic thought.

1. Emotion: How did it make you feel? _ _

2. Physiological Response: What body sensations did you experience? _ _

3. Behavior: What actions did you take? _ _

Underlying Self-Doubt Beliefs

Although the cognitive model maintains that automatic thoughts influence how we react and respond to situations, another important layer adds to the model: underlying self-doubt beliefs. The manner in which we perceive specific situations (and, in turn, the automatic thoughts we have about those situations) are shaped by our underlying beliefs about ourselves, the world, and others. When these underlying beliefs are plagued by self-doubt, it can result in the creation of doubt labels, which act like a filter, biasing the way we view and interpret situations.

Doubt labels (also known as core beliefs) reflect the negative names we call ourselves when our self-doubt is activated. For example, consider a student who is confused by the material being taught in class. Although he wants to ask the teacher for clarification, he refrains from raising his hand because he believes that he is the only person who is confused, and he is convinced that asking a question will further demonstrate his stupidity to everyone in the class. In this case, the student's doubt label is that he is"stupid," and this is what is driving him to think that he is the only one confused. Instead of considering the possibility that other students don't understand the material, that the teacher is doing a poor job explaining the material, or that the material is genuinely difficult, the student assumes that it's his fault.

His belief that he is stupid is what has led him to this conclusion. If the student accepts this conclusion, he will refrain from asking for clarification, which will cause him to perform poorly in the class and serve as a self-fulfilling confirmation of his stupidity.

Therefore, to reduce dysfunctional thinking and behavior, it is important not only to identify and evaluate negative automatic thoughts but also to identify and reframe the doubt labels that are driving these thoughts. For example, if the student in the previous example did not harbor the underlying belief that he is stupid, then he would not automatically assume that he is the only student confused by the material. In turn, he would have the courage to ask the teacher for clarification, which would increase his chances of performing well in the class and confirm a more positive self-concept. Chapter 2 goes into further detail on doubt labels and what drives them so that you can begin to gain a better understanding of how your clients' personal beliefs shape their thoughts, feelings, and behaviors.

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