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Cognitive Behavioural Therapy (CBT) and Negative Automatic Thoughts (NATs)

Cognitive Behavioural Therapy (CBT) and Negative Automatic Thoughts (NATs)

By Dr Steve Last, Edinburgh

Cognitive Behavioural Therapy, or CBT, is a an effective psychotherapy for a wide range of emotional problems. The theory underlying CBT is that our thoughts directly affect the way we feel - if we think in depressed ways then we will feel depressed. As such, a primary aim for a CBT therapist is to help a client recognise when they're thinking in unhelpful ways. This article is a brief overview of one method of doing exactly this. I'll use the example of someone suffering from social anxiety, a common problem amongst people I work with as a Psychiatrist and therapist in Edinburgh.

The first step for the client is to start "recording their thoughts" when they feel anxious - that is, writing down (in brief sentences) what's going through their head. This may sound a little strange at first, but it really is an essential part of the CBT method. Ideally the client should stop and write down what they're thinking at the moment they're thinking it, but writing it down at the end of the day is also acceptable. They should write down everything they were thinking of - this will usually produce quite a list of thoughts and statements and beliefs. In addition, the client should note both how they felt (physically and emotionally) and the situation in which these feelings occurred.

In my example, the client would record that the situation was a social gathering of work colleagues after work. His heart was racing, he felt hot and sweaty, and he was a little light-headed (physical feelings). He described his emotional feeling as "very anxious". Afterwards, when back at home, he wrote down the following thoughts that he remembered having at the time: "I don't know anyone very well", "I've got body odour", "They're all friends", "This place is too busy", "I hate these things", "I want to go home", "I'm going to faint and make a fool of myself", "I've got to get out of here"

This list of thoughts that he has recorded is a list of what a CBT therapist would call "Negative Automatic Thoughts". They're "Negative" in that they tend to hinder the person's motivation and ability to engage with activities, and contribute to emotional problems. They're "Automatic" in that they seem to occur "just like that", popping into the person's head as if from nowhere. Indeed, unless the person specifically focuses his attention on what he's thinking - as in the thought-recording exercise - they may pass unnoticed. All that the person would then be aware of is a sudden feeling of anxiety and a desire to leave the situation.

These Negative Automatic Thoughts (or NATs) cause emotional problems (in this case, social anxiety). Thinking in this way triggers the "Fight or Flight" response to perceived threat, leading to the physical symptoms of anxiety such as a racing heart and nausea. If the person didn't have these NATs (i.e. he didn't think thoughts such as "I'm going to faint") then the "Fight or Flight" response would not kick-in. No physical symptoms of anxiety would result, and he would be free to enjoy the social do.

Having identified the client's NATs, the next step is to find alternative, more helpful ways of thinking about the situation. This is best done by examining the NATs for their rationality or "truthfulness". A CBT therapist (along with the client) does this by conducting a "trial" for a particular NAT. In this example I will take the NAT "I'm going to faint and make a fool of myself" - this NAT was described by the client as the most distressing thought (in CBT parlance, this would be called the "Hot Thought").

In a trial, evidence is presented "for" and "against" the party concerned. It's the same in a trial for Negative Automatic Thoughts. So what evidence is there that the statement "I'm going to faint and make a fool of myself" is true? Very little - the client felt physically unpleasant and was anxious. And the evidence that says the thought is false? Much greater - he didn't actually faint, he's never actually fainted in all the times when he's felt anxious, and it's a well known fear of people experiencing anxiety that they will faint. And besides, there seems little evidence to suggest that even if he did faint, his colleagues would be anything other than concerned about him.

The verdict? That his NAT "I'm going to faint and make a fool of myself" is irrational and false.

Next, it's time to identify an alternative thought that does actually fit with the evidence. How about "My heart is racing and I feel uncomfortable because I'm anxious, but I won't faint and my anxiety will pass with time"? This seems a more accurate statement of the situation, and is clearly less likely to exacerbate his anxiety symptoms. Thinking in this way will reduce his anxiety and enable him to stay out longer with his colleagues, which in turn will help to reduce his anxiety.

Cognitive Behavioural Therapy (CBT) says that "we feel the way we think". An important first step in the recovery from emotional problems is to learn to identify and challenge our irrational thoughts (or "NATs"). As a Psychiatrist and therapist in Edinburgh I have found this to be an effective (and surprisingly quick) way of relieving some of the burden of difficulties such as depression and anxiety. But it is just a first step, and most clients will benefit from a more in-depth CBT approach that addresses not just their Negative Automatic Thoughts but also their Negative Core Beliefs. Please see my other articles on this subject.

Dr Steve Last is a Psychiatrist and therapist based in Edinburgh. He uses CBT techniques to treat common problems such as depression, anxiety, and OCD. Please visit http://www.drstevelast.co.uk for further information about emotional problems and CBT.

About the Author: Dr Steve Last is a Psychiatrist and therapist based in Edinburgh. He uses CBT techniques to treat common problems such as depression, anxiety, and OCD. Please visit http://www.drstevelast.co.uk for further information about emotional problems and CBT.

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