As a licensed professional counselor, I believe that cognitive behavior therapy (CBT) offers clients a natural platform to gain insight into the relationship between thoughts and emotions. Using cognitive behavioral techniques, I invite clients to explore the specific nature and content of their thoughts and examine the ways in which these thoughts influence emotional distress.
Through CBT-oriented trial and error, thought records and behavioral experiments, clients can develop a comprehensive tool belt for responding to stressful events in a self-structured and practical manner. The active identification and disputation of negative thinking leads to improved emotional states and healthier behavioral reactions. I often introduce this concept as an enhanced version of the common treatment goal of learning how to “think prior to reacting.”
Framework
Before an individual forms an emotion, that individual needs to observe an event. This event can be a person, place, thing or activity. The important criteria here is not what the individual observes but simply the fact that an event has been noticed.
Once an event is observed by the individual, the brain produces a thought. A thought is very different from an emotion. A thought is a statement that is verbalized or experienced silently. A thought has sentence structure. Every thought has punctuation. Some thoughts end in a period. Some thoughts end in a question mark. Some thoughts end in an exclamation mark. It is important for the counselor to offer this education to the client. To experience success with CBT coping tools, it is essential for the client to be able to differentiate between thoughts and emotions.
Once a thought is produced and experienced by the individual, an emotion is formed. I tell my clients that in some cases, it feels as if the emotion occurs before the thought, but CBT tells us this is not exactly true.
Individuals experience emotions as an internal continuum of distress. This means that emotions can fluctuate from low distress to moderate distress to high distress. Most of the time, individuals will experience emotions consistent with mad, sad, glad or fearful. The continuum of emotional distress is often experienced parallel to physical symptoms. In other words, certain emotional states will produce certain physical symptoms. Counselors can assist clients in recognizing which physical symptoms are most typically associated with each emotional state.
For example, the emotional state of mad often occurs parallel to a headache or clenched fists. The emotional state of sad often occurs with tearfulness and internal weight between the stomach and lungs. The emotional state of glad most often occurs with smiling or laughter. The emotional state of fear most often occurs with a rush of adrenaline, quickening heart rate and sweaty palms. Of course, individuals can experience many other emotional labels and physical 
symptoms, but acquiring this basic education about emotion-body response can enhance our clients’ abilities to more clearly identify what they are feeling at any given time. This also provides clients with another important layer in understanding the difference between thoughts and emotions.
Once an emotional state is experienced, a behavioral reaction will be provoked. A behavioral reaction is simply something that the individual says or does that leads to a desirable or undesirable environmental/social outcome. Behavioral reactions that lead to undesirable outcomes typically create more barriers and perpetuate the cycle of life problems. Positive behavioral reactions lead to desirable outcomes and ignite a cycle of positive change.
The key to all of this is for individuals to identify where they can initiate intervention in their cognitive behavioral processes. Intervention can occur immediately after thoughts or immediately after the formation of the emotion. As long as intervention is implemented prior to the behavioral reaction, then positive change can take place.
Counselors can assist clients in building cognitive behavioral skills through the examination of self-talk. Self-talk is another term used for thought. Because thoughts have sentence structure to them, the sentence content in our thoughts is directly responsible for the formation of emotion.
Certain “words” increase emotional distress when they are experienced within our self-talk. One of the biggest culprits is the word “should.” When individuals experience “should” in their thoughts, it produces an emotional state associated with a demand to achieve extreme standards or ideals. The emotional consequence is likely to be guilt, frustration or depression. When directing their “should” thoughts toward others, individuals are likely to feel anger and resentment.
Protocol/intervention
I have developed the following intervention as a tool that counselors can use with clients consumed with persistent “should” thoughts and who identify unpleasant emotional responses that have led to patterns of undesirable behavioral reactions and environmental/social consequences. The intervention’s goal is to offer a protocol for effective identification, practice, application and implementation of cognitive restructuring, specifically in the context of problematic “should” thoughts.
S-H-O-U-L-D
Say: It is important to encourage the client to verbalize the “should” thought out loud. This brings life to the negative thought process and makes the negative self-talk a concrete, tangible item to work on in the counseling process. It also creates a safe opportunity for the counselor and client to work at restructuring negative internal dialogue within the realm of trust and rapport that they have developed.
Counselor: “Help me understand these should thoughts. I would like to invite you to verbalize them out loud to me.”
Client: “I should not feel depressed. I have no reason to be depressed.”
Hold: It is important for the client to learn to tolerate the distress created from the negative self-talk. The counselor encourages the client to practice tolerating the emotional discomfort through a pause and delay. This creates an opportunity to enhance distress tolerance ability, while engaging in safe examination of the negative self-talk.
Counselor: “There is pressure to react to these emotions. Try not to react. Let’s slow things down so we can address this rationally. I would like you to try and sit with these emotions, in the presence of my support, for as long as you can tolerate. Let’s try to pause and delay a reaction for one to two minutes.”
Client: “I will try my best.”
Offer: The counselor and client engage in a discussion of possible alternative ways of thinking that could potentially lead to more desirable emotional states and healthier behavioral reactions. This is a brief trial-and-error component within the intervention. The counselor will engage with the client in a balanced, rotational practice of coping thoughts.
Counselor: “If we were to remove the word should from your negative self-talk, what can we replace it with that might reduce the emotional pressure that you feel? Let’s discuss all the possibilities together.”
Undo: It is important to identify one coping thought that the client can continue to practice within his or her routine internal dialogue. For example, the counselor might ask the client to write one coping thought on an index card that can be kept in a safe, visual space. This encourages proactive, routine practice of healthier self-talk. It also makes the coping thought a concrete, tangible tool that can be used both in the present and in the future, as needed, in the context of counseling goals.
Counselor: “Which one of the coping thoughts that we discussed today do you feel you could continue to utilize as positive self-talk during future episodes of distress?”
Client: “I have experienced depression for a reason. I have permission to feel how I feel. I am always working on finding ways to cope with my life stressors, and I am doing the best that I can.”
Learn: The counselor and the client identify a homework assignment or task for the client to complete that encourages ongoing utilization of this tool. For example, the counselor might invite the client to begin a thought log, in which the client actively records dates and times when the tool is utilized and how effective it was in reducing emotional distress or contributing to healthier behavioral reactions. This provides opportunities for the client to begin constructing a cognitive behavioral blueprint for effective thought substitution.
Counselor: “I would like to introduce you to an exercise called a thought log. This will provide you with a platform to practice replacing ‘should’ thoughts with more positive self-talk this coming week. Remember, the most effective change takes place when you can take the skills learned in counseling and apply them to situations outside of these office walls.”
Do: Follow-up is essential to the counseling process. If the counselor and client agree on homework assignments or behavioral experiments, it is important for the counselor to follow up with the client to examine the client’s beliefs about what is effective versus ineffective. This holds both the counselor and the client accountable for maintaining diligence and dedication in their roles within the counseling relationship.
Counselor: “In the prior session, we discussed problematic ‘should’ thoughts, and I offered you the assignment of a thought log. How did you do with that?”
Conclusion
As a professional counselor, I am always looking for ways to enhance my practice and also share my interpretation of theories and treatment approaches. I hope that this piece will help you reflect on ways in which you may be able to use a tool such as the one I described with the clients you serve. Through continued consultation, collaboration and publication, mental health professionals can become unified in our mission to initiate genuine counseling processes that contribute to the enhanced well-being of our clients. I would love to hear your feedback on how this CBT tool is working for you and the individuals you serve.
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Brandon S. Ballantyne is a licensed professional counselor and national certified counselor who has been practicing clinically since 2007. He currently practices at Reading Health System in Reading, Pennsylvania, and Advanced Counseling and Research Services in Lancaster. He has a specialized interest in using cognitive theory to help his clients recognize problematic thought patterns and achieve more desirable emotions and healthier behavioral responses. Contact him at Brandon.Ballantyne@readinghealth.org.
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Other articles by Brandon S. Ballantyne, from the Counseling Today archives:
- “Assessing ‘ideal’ versus ‘real’ family characteristics with adolescents” https://wp.me/p2BxKN-3Uo
- “Where’s Waldo? A creative tool to introduce CBT skills” https://wp.me/p2BxKN-45K
- “Helping clients realize their daily potential” https://wp.me/p2BxKN-4lw
- “The Social Adventures and Experiments of Tommy Joe Peterson” https://wp.me/p2BxKN-4Bo
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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.