Cognitive Behavioral Therapy, or CBT, is an effective psychotherapy for a wide range of emotional problems. The underlying theory of CBT is that our thoughts directly affect the way we feel: if we think in a depressed way, we will feel depressed. As such, a primary goal for a CBT therapist is to help a client recognize when she is thinking unhelpfully. This article is a brief description of a method to do exactly this. I will use the example of someone who suffers from social anxiety, a common problem among the people I work with as a psychiatrist and therapist in Edinburgh.

The first step for the client is to begin to “record their thoughts” when they feel anxious, that is, to write down (in short sentences) what is going on in their head. This may sound a bit strange at first, but it really is an essential part of the CBT method. Ideally, the client should stop and write down what he is thinking at the moment he is thinking it, but it is also acceptable to write it down at the end of the day. They must write down everything they were thinking; this will usually produce a fairly large list of thoughts, statements, and beliefs. In addition, the client should write down 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 an after-work social gathering of co-workers. His heart was racing, he felt hot and sweaty, and he was a little dizzy (physical feelings). He described the emotional feeling from him as “very anxious.” Later, back at home, he wrote down the following thoughts that he remembered having at the time: “I don’t know anyone very well”, “I have bad body odor”, “They are all friends”, “This place is very busy”, ” I hate these things”, “I want to go home”, “I’m going to pass out and make a fool of myself”, “I have to get out of here”.

This list of thoughts that you have recorded is a list of what a CBT therapist would call “Negative Automatic Thoughts.” They are “negative” in the sense that they tend to hinder a person’s motivation and ability to participate in activities and contribute to emotional problems. They are “automatic” in the sense that they seem to occur “just like that”, appearing in the person’s head as if out of nowhere. In fact, unless the person specifically focuses her attention on what he is thinking, as in the thought-logging exercise, they may go unnoticed. All the person would then perceive would be 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 this way triggers the “fight or flight” response to the perceived threat, leading to the physical symptoms of anxiety, such as a racing heart and nausea. If the person did not have these NATs (ie, did not think thoughts like “I am going to faint”), then the “Fight or Flight” response would not be triggered. There would be no physical symptoms of anxiety and you would be free to enjoy social activity.

Having identified the client’s NATs, the next step is to find alternative and more useful ways of thinking about the situation. This is best done by examining NATs for their rationality or “trueness”. A CBT therapist (along with the client) does this by performing a “test” for a particular NAT. In this example, I’ll take the “I’m going to pass out and make a fool of myself” NAT: The client described this NAT 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 in question. It is the same in a Negative Automatic Thoughts test. So what evidence is there that the statement “I’m going to pass out and make a fool of myself” is true? Very little: the client felt physically and was unpleasantly anxious. What about the evidence that says the thought is false? Much greater: he didn’t actually pass out, never passed out at all times when he felt anxious, and it’s a well-known fear of people experiencing anxiety of passing out. And furthermore, there seems to be little evidence to suggest that even if he passed out, his colleagues wouldn’t be concerned about him.

The verdict? That your NAT “I’m going to pass out and make a fool of myself” is irrational and untrue.

Next, it’s time to identify an alternative thought that really fits the evidence. How about “My heart is racing and I feel uncomfortable because I’m anxious, but I won’t pass out and my anxiety will pass over time”? This seems like a more accurate statement of the situation and is clearly less likely to exacerbate your anxiety symptoms. Thinking this way will reduce your anxiety and allow you to spend more time with your colleagues, which in turn will help reduce your anxiety.

Cognitive Behavioral Therapy (CBT) says that “we feel as we think.” An important first step in recovery from emotional problems is learning 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 to ease some of the burden of difficulties like depression and anxiety. But it’s only a first step, and most clients will benefit from a more in-depth CBT approach that addresses not only their negative automatic thoughts, but also their negative core beliefs. Please see my other articles on this subject.