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Advances in Psychiatric Treatment (2002), vol. 8, pp. 377–386
Unhelpful thinking APT (2002), vol. 8, p. 377
Identifying and challenging
unhelpful thinking
Chris Williams & Anne Garland
This is the third in a series of papers that address how to
offer practical cognitive–behavioural therapy (CBT) inter- Altered thinking
ventions within everyday clinical settings. The first two in different mental disorders
papers (Williams & Garland, 2002; Wright et al, 2002)
describe the Five Areas Assessment model and its
application. The final two (Garland et al, 2002; Whitfield Experimental research data (e.g. Williams &
& Williams, 2002) will cover overcoming problems of Dritschel, 1988; Dalgleish & Watts, 1990) have
altered behaviour (reduced activity and avoidance) and confirmed that both the processing styles and the
summarise the evidence base for the effectiveness of CBT. content of thinking vary in different emotional
states.
In the first two articles of this series (Williams &
Garland, 2002; Wright et al, 2002), we looked at the Characteristic changes
different areas of human experience that alter during in thinking in depression
times of mental illness. The Five Areas Assessment
model (Williams, 2001; see also Fig. 1 of Williams &
Garland, 2002) provides a clear summary of the Patients with depresssion are more negative about
range of problems and difficulties faced by the things when compared with other clinical groups
individual in each of the following domains: and controls (Hagga et al, 1991). Beck et al’s (1979)
1 life situation, relationships, practical problems model proposes the negative cognitive triad, with a
2 altered thinking negative view of self, the world and the future – this
3 altered emotions (moods or feelings) model is also supported by research evidence
4 altered physical feelings/symptoms (Blackburn & Eunson, 1989). In addition, patients
5 altered behaviour or activity levels. with depression have impaired problem-solving
The Five Areas model shows that what individuals skills (Nezu et al, 1989). Furthermore, they take longer
think about a situation or problem may affect how to retrieve positive memories and are more readily
they feel emotionally and physically and also alter able to access negative memories (Clark & Teasdale,
what they do. The five areas are interdependent, each 1982). This might explain the common clinical
exerting an influence over the others. situation when such patients tell you that they have
‘done nothing’ over recent weeks, despite evidence
to the contrary – they are simply remembering the
This article is based on material contained in Structured negative and overlooking the things that they have
Psychosocial InteRventions In Teams: SPIRIT Trainers’ achieved. These thoughts lead to altered behaviour
Manual. Further details available from the author upon such as reduced activity or unhelpful behaviours
request. (Fox et al, 2002).
Chris Williams, a senior lecturer in psychiatry (Department of Psychological Medicine, Academic Centre, Gartnavel Royal
Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK) is President of the British Association for Behavioural and
Cognitive Psychotherapies (BABCP) and a member of the Royal College of Psychiatrists’ Psychotherapy Faculty Executive.
His main interest is in the role of depression as a predictor of outcome in patients with medical illness. Anne Garland, a nurse
consultant in psychological therapies (Regional Psychotherapy Unit, St Ann’s House, London) is a member of the Accreditation
and Registration Sub-Committee of BABCP and a well-known CBT trainer and researcher.
https://doi.org/10.1192/apt.8.5.377 Published online by Cambridge University Press
APT (2002), vol. 8, p. 378 Williams & Garland
Characteristic changes in thinking Characteristic thinking associated
in anxiety disorders with shame
In contrast to the negative content of thought in The content of thoughts associated with shame is
depression, for patients with anxiety disorders derived from individuals’ perceptions that they have
(panic disorder, agoraphobia, generalised anxiety undesirable qualities (e.g. physical appearance,
and phobic disorders) common thinking themes are emotions, personality traits) or behaviours/actions
an increased perception of danger and threat which, if revealed to others, will result in ridicule
combined with a decreased perception of their own and humiliation. The thought that they are total
ability to cope with that danger. Typical thoughts failures and that others see them in this way drives
and images include themes of vulnerability, loss of their behaviours, which aim to hide these un-
control, fear of social ridicule, physical harm and desirable qualities (Gilbert, 1998).
death (Beck & Emery, 1985). In terms of how
information is processed, anxious patients are more
prone to scan for potential threats than are controls Finding a language
and they have lower thresholds for noticing
potential threats (Mathews & MacLeod, 1986). The for altered thinking
result is the avoidance of anxiety-provoking
situations, or the start of unhelpful behaviours such
as reassurance-seeking, drinking to excess or The traditional language of cognitive–behavioural
misusing sedative medication (Fox et al, 2002). therapy (CBT) describes the thoughts summarised
above as negative automatic thoughts, which show
Characteristic thinking associated a range of thinking errors or cognitive distortions.
with anger In developing the Five Areas model, the language
used was extensively tested by a range of health
Beck (1976) suggests that the content of thoughts care practitioners who used the approach with their
associated with anger is derived from a perception patients (Williams & Whitfield, 2001). It was found
that someone else has broken an individual’s that the concept of negative automatic thoughts failed
idiosyncratic rules of what is fair and just, or acts to to use an easily accessible language and required
threaten or frustrate the individual in some way. quite a lot of explaining to patients. It was also
Typical thoughts include ‘shouldn’t’ or ‘mustn’t’ reported that the term ‘thinking error’ led to mis-
statements (‘She shouldn’t say that to me!’), or taking understanding in some patients with depression,
things personally (‘He is doing that on purpose’). who concluded not only that they were depressed,
The individual may jump to the conclusion that the but also that they were thinking wrongly. As a result,
other person is completely bad (‘He’s a total git’) the Five Areas model instead uses the term ‘extreme
and this leads to actions such as making critical and unhelpful thoughts’. These are thoughts that
comments or attacking the other person, either show one of the unhelpful thinking styles. This can
actively or passively. be defined either in terms of the content of thoughts
or the way in which information is processed (e.g.
focusing on the negative aspects of a situation or an
Characteristic thinking associated increased likelihood of perceiving danger in
with guilt situations that are quite safe). The goal of treatment
is therefore to help individuals to become aware of
The content of thoughts associated with guilt is their unhelpful thinking styles and their impact, and
derived from a perception that the individual has to teach them skills for challenging these in order to
broken his or her own idiosyncratic rules of what is move towards more balanced and helpful thoughts.
fair and just. Typical examples include statements
such as ‘I should have done that’ or self-critical Implications for assessment
thoughts such as ‘It’s my fault’ and frequently
involve themes of excessive responsibility-taking
and underlying rules to put duty before all else
(Beck, 1976). Individuals may judge themselves to Cognitive–behavioural therapists emphasise
be totally bad and overlook their strengths. They unhelpful thinking styles because they recognise a
may act in ways that confirm this by setting link between the view individuals take of a situation
themselves up to fail or taking part in self-punishing and the impact that this has on how they feel
behaviours such as deliberate self-harm. emotionally and physically, and on the altered
https://doi.org/10.1192/apt.8.5.377 Published online by Cambridge University Press
Unhelpful thinking APT (2002), vol. 8, p. 379
behaviours that result. Because this article aims to What people think can affect what
describe a generic model, the examples we give they do
address two of the most common psychiatric
presentations – anxiety and depression. Extreme thoughts may lead individuals to reduce
What people think can affect how or stop doing activities that previously gave them a
sense of pleasure or achievement, or to start doing
they feel emotionally things that actually worsen how they feel. This
establishes a reciprocal relationship between
The Five Areas Assessment model summarises the extreme thinking and reduced/avoided activities or
reciprocal links between mood state (e.g. anxiety or unhelpful behaviours.
depression) and altered thinking. Thus, adverse Example
changes in mood are associated with extreme and The effect of reducing activities is often to reduce
unhelpful thoughts (i.e. thoughts that are more doing things that would have provided a sense of
negative or catastrophic). For example, if an pleasure or achievement, thus adding to depression.
individual experiences thoughts that other people Similarly, in anxiety individuals may avoid anxiety-
do not like him, or perceives himself to be inferior to provoking situations. They may also try to block
others, or sees the future as bleak and constantly adverse emotional states such as fear, anxiety,
predicts that everything he does is bound to go shame, anger or depression by using unhelpful
wrong, he is likely to feel more anxious and/or behaviours such as drinking (these three responses
depressed. Similarly, if mood changes for the worse are the focus of the next article in this series, by
then thinking is likely to become more extreme and Fox et al, 2002). The resulting patterns of
unhelpful. In this way a reciprocal relationship is behaviour have an unhelpful impact on how
established between extreme thinking and altered individuals feel, by causing adverse physical,
mood. psychological and social consequences in the short
or longer term. The altered behaviour again acts
Example to keep the depression or anxiety going.
A common clinical example that illustrates this point These links between thoughts and behaviours
is seen in patients who have experienced traumatic can be identified by asking questions such as: ‘When
upset and have subsequently developed depression. you noticed the thought “They think I’m an idiot
As the depression becomes prominent, they begin and will end up rejecting me”, which you believed
to notice more intrusive and upsetting memories of 95%, did that have any influence on what you did
what happened, which further adds to their emotional as a result? Is it possible that the thought and the
distress. Here, the extreme and unhelpful thoughts fact that you suddenly left the pub are linked here?’
act to keep the depression going. As the depression
responds to treatment, the intrusive memories often
reduce and the individuals are less bothered by them. Interaction between the
This reciprocal relationship can be identified by five key areas
looking at a specific time when mood has worsened
and then asking a series of questions such as:
‘When you were in the pub with your friends at what
point did you feel most anxious?’ Box 1 gives an example of how situations, thoughts,
‘How anxious did you feel at that time on a scale of 0 emotional and physical feelings and altered
to 100, where 0 is feeling no anxiety at all and 100 is behaviour link together. These changes may be
the most anxious you have ever felt?’ linked to each of the areas in the Five Areas
‘At that moment when you came back from the toilet Assessment model.
and your friends were all laughing and you felt The example in Box 1 illustrates that what we
95% anxious, what was going through your mind?’ think affects how we feel and what we do. It is
‘When you noticed the thought “They think I’m an not situations in themselves that mediate our
idiot and will end up rejecting me”, how much did emotional responses, but our interpretation or
you believe it at the time, on the same 0 to 100 view of events. In depression and anxiety, people
scale?’ become overly prone to interpreting very many
‘Is it possible that that thought and how anxious you
felt are linked?’ things in the extreme and unhelpful ways
The aim of this series of questions is to identify and described above. This type of thinking gets outs
rate the belief in an extreme and unhelpful thought, of proportion and unhelpfully affects people’s
and at the same time teach the individual skills in feelings and actions. As a treatment, CBT aims
recognising the links between his thoughts and to identify and improve the unhelpfully altered
feelings. thinking and behaviours.
https://doi.org/10.1192/apt.8.5.377 Published online by Cambridge University Press
APT (2002), vol. 8, p. 380 Williams & Garland
Box 1 How the five key areas interact
Imagine that you are experiencing a depressive disorder.
Situation As you are walking down a road, someone you know well walks by and doesn’t speak to you.
Altered thinking You could explain this to yourself in a number of ways. Let us say that you jumped to
the very negative conclusion that ‘She doesn’t like me’ and you believed this 80%.
Altered physical feelings You might notice some altered physical symptoms such as feeling low in energy
and restless; that evening you may have difficulty sleeping.
Altered emotional feelings This might lead to altered emotions (feeling even lower in mood).
Altered behaviour Your altered physical and emotional feelings may cause you to go home and avoid
company. In the longer term you might possibly avoid the person or act differently towards her.
Your extreme and unhelpful thoughts and altered behaviour in this instance may act to keep your
depression going: your avoidance of this friend in future will prevent you from recognising that
your interpretation of her behaviour was both unhelpful and untrue. Your actions end up reducing
your confidence still further and maintaining your depression.
But you may have misinterpreted your friend’s behaviour:
Situation As you are walking down a road, someone you know well walks by and doesn’t say anything
to you. You happen to know that she has just received some bad news.
Altered thinking You might then have thought, ‘She was upset and preoccupied and just didn’t see me’
and believed this 100%.
Altered physical feelings You might therefore not have experienced any significant physical changes.
Altered emotional feelings You might have felt empathy for her.
Altered behaviour You might have gone out of your way to talk to her.
How common are the unhelpful acting to keep the person feeling distressed, and/or
thinking styles? acting in ways that add to and maintain the
problems. Identifying recurrent patterns of un-
Experiment helpful thinking styles provides targets for change
Consider the following three situations. Read each that can improve how the person feels.
statement as if it were happening to you right now It should be noted that the CBT approach does
and write down the immediate thoughts that pop not argue that depression or anxiety are directly
into your mind. Then examine each thought and caused by extreme and unhelpful thinking. Rather,
identify the unhelpful thinking styles outlined in Table it argues that such thinking is present during times
1 that are characteristic of these thoughts. of depression and/or anxiety. Such thinking is
1 You have gone into town to meet your friend at therefore most usefully formulated as a symptom of
10.00 am, but he does not turn up. depression and anxiety. Since the five areas de-
2 You are giving a talk at a management meeting scribed in the model are interdependent, intervening
and you notice someone in the audience yawning. in any one of these domains should be sufficient to
3 You go to do some last-minute photocopying for lead to improvement in the remaining domains.
a presentation for a job interview. The machine Identifying and modifying extreme and unhelpful
jams halfway through. It needs the engineer. thinking can therefore be an effective intervention
In large group-teaching sessions of health care prac- and may be combined with other interventions, such
titioners, when asking attendees how many of the as planning a step-by-step increase in activity (the
unhelpful thinking styles they have noticed in them- altered behaviour domain) or taking antidepressant
selves (the task completed in the above experiment), medication (the altered physical symptoms domain).
the median is always 3 or 4. Fewer people show 5 or A couple of rules of thumb are as follows:
6, or only 1 or 2 of these styles. This illustrates that
unhelpful styles of thinking occur in all of us from • typically, one or two unhelpful thinking styles
time to time. A key difference during times of mental predominate and occur repeatedly;
disorder is that these thoughts become more frequent • the crucial thing is to help patients to under-
and more intrusive (i.e. they have a higher frequency stand the relationship between altered thinking,
and duration) and become harder to dismiss (i.e. altered feelings (both emotional and physical)
they are believed more). As a result, extreme and and altered behaviour and the role this plays
unhelpful thinking becomes part of the problem, by in maintaining current problems.
https://doi.org/10.1192/apt.8.5.377 Published online by Cambridge University Press
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