Doing CBT Backwards: Using Journaling to Change Thinking

The most cliché expression in psychotherapy is “How does that make you feel?” Though seemingly innocuous, this statement implies that a patient’s feelings are caused by factors outside of his/her control. Suppose, instead, one asks the patient, “How do you want to feel?” Patients often respond to this with surprise as this question suggests that they can, if they choose, have some control over their own feelings.

This is doing CBT backwards: Begin by determining what the patient wants to feel, then determine what thoughts will help them get there. Described here is one method to enable patients to do this, using journaling to help patients change their thoughts, interpretations, and assumptions.

Even if patients feel they cannot control their thoughts (e.g., OCD, Anxiety disorder, self-loathing), in fact, especially if they feel they cannot control their thoughts, training in thinking can help many patients gain some control, introduce positive thoughts, and begin to crowd out automatic negative thoughts.

The method presented here uses guided journaling. Following is a step-by-step guide.

Step 1: Ask the patient to create at least one journal entry each day to describe an important event that occurred that day. In a therapy session, review the patient’s journal to give the patient an opportunity to talk about the events, and why they were important.

Step 2: Once the patient becomes skilled at creating brief journal entries, ask him/her to add to each journal entry a description of what thoughts s/he had when the events occurred, or thoughts about the events. In session, review the journal and discuss the thoughts the patient had during the event, or after. What did it mean to him/her? How did s/he interpret what was going on at the time?

Step 3: After one or two weeks of recording events and thoughts in his/her journal, ask the patient to record the feelings s/he felt when the event occurred. In session, review the journal entries and discuss the causal linkage between the thoughts and interpretations the patient had about the events, and his/her resulting feelings. Discuss how interpretation of events – which are often based on overlearned assumptions, often defensive, that “flash” in one’s mind – cause the feelings that result.

Step 4: As the patient comes to understand the linkage between his/her thoughts (interpretations, assumptions) and feelings, challenge him/her to create alternate interpretations of the events; that is, different ways to explain them.

It is Important to point out to the patient not to try to get rid of negative thoughts right away. Some patients will exhibit all-or-none thinking: If I still have negative thoughts, the procedure is not working. Explain that we want to introduce and practice healthy thinking, positive thoughts, as a way to replace or “crowd out” unhealthy obsessive thinking. This takes practice and time.

Also point out to the patient that s/he will not experience strict control over his/her thoughts and feelings, but with practice will experience some influence. The choice to have more positive feelings comes from practice creating alternative explanations and interpretations for events that result in positive feelings. Over time, these positive thoughts become assumptions that replace old negative assumptions. Example: Did the driver of the BMW who just cut in front of you on the freeway do this on purpose, or because he is a neurosurgeon rushing to a hospital to save the life of a little girl? The two interpretations will result in very different feelings, and there is nothing stopping you from entertaining either thought.

To help my patients better manage their thinking, I use a product called CaseKeepers that gives me visibility into their journal and the ability to shape their thinking between sessions, thereby accelerating the process.

In my next blog entry, “CBT Backwards: An Example “, I will present an example to demonstrate the technique.