Free for Download: Prompt Cards for Conversations about Cognitive Distortions

Earlier this year I employed an illustrator to help me develop some prompt cards to use in session with clients, stimulate conversation, and add a visual component to further explain some of the unhelpful thinking styles commonly seen in anxiety, depression, and other psychological difficulties. I think they have come together really well and the illustrations do help to explain each distortion in a different way. Now I am offering them up for free download. If you have any questions or comments about the cards, I would be glad to hear from you. Simply send me an email here:

Challenging Behaviour – Functional Behavioural Assessment

At times, individuals with neurodevelopmental disorders (i.e. Autism, Intellectual Disability, ADHD) can behave in ways that are challenging to those around them. The behaviours may be directed toward others, or toward themselves and can be highly distressing for the individual, carers, and those around them. Behaviours are most distressing and challenging when they cause harm to other people or the individual. Common harmful behaviours include:

Behaviour toward others

  • Hitting others with hands
  • Hitting others with objects
  • Scratching others
  • Pulling hair of others
  • Pinching others
  • Biting others
  • Pushing or pulling others
  • Head-butting others
  • Choking others

Behaviour toward self

  • Skin picking self
  • Biting self
  • Head punching/slapping self
  • Head to object banging self
  • Body to object banging self
  • Hair removal self
  • Body punching or slapping self
  • Eye poking self
  • Banging with tools self
  • Lip chewing self
  • Nail removal self
  • Teeth banging self

Often individuals with these types of neurodevelopmental disorders are unable to communicate the reason’s why they are completing these behaviours, and so a behavioural practitioner is employed to complete a functional behavioural assessment to make some hypotheses about why. The practitioner is interested in the function of the behaviour, (or the motivation behind the behaviour) and this is where the name functional behaviour assessment comes from.

So, WTF?

No, not that what the… actually we are always asking: what is the function?

Behaviours can generally be separated into four or five functional categories:

  1. Social Interaction

Individuals may display behaviours as a means to communicate with others and gain social attention or interaction. For example, the boy who throws an object in another child’s direction as a way to get their attention, or the girl who pulls another girls hair.

2. Escape

Behaviours may be used as a means to escape certain undesirable activities or environments. For example, the teenager who yells and screams when asked to start doing their homework, or the adult who runs toward traffic when getting in the car to go to the GP.

3. Non-social (Sensory)

Self-stimulation and repetitive behaviours may be used to reach a desired level or arousal, or as a way to reduce discomfort or anxiety. For example, the woman who picks at her skin, or the boy who isolates to his room and plays video games repetitively.

4. Tangible

Behaviours may be used to gain access to tangible resources such as money, food, games, or toys. For example the toddler who kicks and screams until they are given their favourite snack, or the man who hits himself in the head when he is not able to buy a soft drink, only to be given the soft drink to de-escalate the situation.

Its not just people with neurodevelopmental concerns who display challenging behaviours. We all do at times. Have a think about a time when you became frustrated and instead of communicating with language, you communicated with behaviour. If you drive a motor-vehicle, have you ever tooted your car horn at a fellow motorist in anger? This could be considered a challenging behaviour to other motorists and may cause some distress. Of course this is quite benign example but I hope it illustrates my point that challenging behaviours exist on a continuum from and can be considered normal in many ways.

Fortunately, most of us have reasonably well developed skills to problem solve, navigate the world, inhibit our impulses, and express our needs through language. However, when individuals are unable or unwilling to communicate the reasons why they perform certain behaviours, those who care and support the individual can be left perplexed and feel powerless to make change. They wish to reduce or contain the behaviour so that the individual and those around them are safe.

This is where the behavioural practitioner can help to determine the function of the behaviour. Once a hypothesis is made about the function of the behaviour, the behavioural practitioner can then make recommendations to reduce the likelihood that the behaviour will occur. Identified triggers can be minimised, and alternative behaviours which meet the individuals needs can be taught. Any factors that may be inadvertently rewarding the behaviour(s) can be avoided. Staff can also be trained in appropriate ways to respond to challenging behaviours and trained in strategies to teach alternative behaviours.

Working to reduce challenging behaviours is an ongoing process, and is grounded in the scientific method where hypotheses about the function of the behaviour are made, interventions are applied, and reviewed for their effectiveness. If the interventions are effective, brilliant! If not, the hypotheses and interventions are modified and trialled again. Of course, in the end, this process is about improving the quality of life of the individual, and equipping supports and caregivers with the tools necessary to keep the individual and those around them safe and well.

Study Habits – PATS

Employing focussing strategies can help students maximise their study time and remember more information. If an environment is less distracting, students are more likely to be able to manipulate information in their mind. In turn, students will be better able to remember the information over time. Furthermore, if students employ strategies to self-monitor how distracted they are, it is more likely they will be able to focus. This strategy uses the mnemonic acronym, PATS, which stands for:

Pick the right environment to study:

  • Pick a good place to study that is comfortable. Consider how quiet the place should be, how busy it should be, and how bright it should be (bright light can be distracting and low light can make it difficult to see).
  • Set aside a dedicated place to study. A student’s mind might be confused and distracted by trying to study in bed, for example, because a bed is associated with sleeping.

Always reduce visual distractions:

  • Find a place such as at a desk facing away from other distracting activity.
  • Only have the necessary material. Other books, toys, magazines, and computers can be distracting.

Try to eliminate noise around you.

  • Study in a quiet room. Lights and fans may contribute noise, so earplugs may be helpful.
  • Some people like to study with music. Be sure it is not distracting. If it is, pick a quieter volume or different style of music.

Self-talk to control internal distractions.

  • Some students may be distracted by internal factors such as thoughts about other things, hunger, or worry. Students should monitor their internal distractions and use positive self-talk to focus.
  • For example, if a student is eager to e-mail a friend, the student should say to themselves, “I’m distracted by wanting to e-mail, but I need to study more. I’ll study for 15 more minutes and then take a break to e-mail.” In this example, a timer would be a great way to help quantify study time and focus.

Students should be explicitly taught PATS and guided to use it. During class or study at home, a teacher or parent can remind the student to use PATS when they need to really focus and remember information.

Source: The Comprehensive Executive Functioning Inventory

Autism – Teaching Daily Living Skills

For some people on the spectrum, daily living skills may be more difficult to learn than for normally developing individuals their age. To teach a skill that has not yet developed, caregivers should be able to help the individual break the skill down into multiple steps. By breaking the task down into each step, caregivers can teach the skill in phases so the individual can become increasingly independent. Caregivers can learn about task analysis implementation to improve their teaching skills. Task analysis includes the following six steps:

  1. Task identification
  2. Required prerequisite skills and materials needed
  3. Breaking the task into steps
  4. Confirming that the task is completely analysed
  5. Determining how the skill will be taught
  6. Teaching the skills and monitoring progress 

So how do we teach these skills…….

My suggestion is video modelling

Most of us carry a mobile phone with us throughout the day, and people on the spectrum often have an affinity with technology. Besides, video modelling is well supported by the academic literature as an evidence-based intervention for teaching new skills to those on the Autism Spectrum. A brief search of the ProQuest Medline database yielded 1809 results for the search term “video modelling and video prompting autism”. The first 20 results included video modelling interventions for a wide variety of behaviours including:

  • General Task Completion
  • Functional Skills
  • Role Playing Skills
  • Social Language Skills
  • Vocational Skills
  • Imitation
  • Finding a Word in the Dictionary
  • Safe Pedestrian Skills
  • Transitional Skills
  • Active Video Game Skills
  • Play
  • Toilet Training

The following table presents four types of video modelling appropriate for learning different skills in different settings:

TypeDescription
Basic Video ModellingOther adults, children, or animations demonstrate the behaviour or skill
Video Self-ModellingThe individual models the behaviour while being guided and recorded by a trainer
Point of View Video ModellingThe video is recorded in first person view, so that the individual can learn what the behaviour looks like (particularly useful for seeing hand movements)
Video-PromptingDirections are given by a trainer in a stepwise fashion
Types of Video Modelling

There are four main steps to implementing video modelling interventions to develop new skills. The first is to plan the intervention, next the video is made, followed by implementing the video with the person with ASD, and then follow-up.

Step 1.Select a target behaviour, choose the equipment, break down the target behaviour by writing a task analysis.
Step 2.Decide on the type of video modelling, consider other factors (i.e. location), and then create the video.
Step 3.Decide on the equipment used to show the video, prepare (i.e. ensure the devices are charged), show the video on a regular schedule.
Step 4.Monitor the intervention, troubleshoot and resolve barriers to learning, fade the video, decide whether to expand the video to a related skill or move to a new one.
Video Modelling Process

Effective implementation has been demonstrated through a single case study design by Shrestha, Anderson, and Moore (2013), ‘Using Point-Of-View Modelling and Forward Chaining to Teach a Functional Self-Help Skill to a Child with Autism’ in ‘The Journal of Behavioural Education’ as demonstrated by the following direct quote.

“Three videos were produced, one for each phase, with John’s mother as the model. As the videos were intended to represent the participant’s point-of-view, the camera was held over the model’s shoulders showing two hands completing the tasks, with a voiceover explaining the steps. The first video, which began with a voiceover providing an initial prompt to start the task, saying, ‘‘I’m hungry! Let’s get some Weetbix without any help!’’ included a visual representation of Steps 1–4, and was 2 min 6 s in duration. The second video included Steps 1–10 and was 3 min 28 s long. The final video was 3 min and 45 s and included Steps 1–13. All three videos included verbal praise, ‘‘Great job!’’, at the end.

1) Get a bowl from the drawer

2) Get a spoon from the drawer

3) Get Weetbix from the cupboard

4) Get soy milk from the fridge

5) Put two Weetbix in the bowl

6) Open the lid of the milk bottle

7) Pour some milk in the bowl just enough so the Weetbix can still be seen

8) Close the lid of the milk bottle

9) Break the Weetbix up

10) Eat

11) Take the bowl over to the sink

12) Put the Weetbix back in the cupboard

13) Put the milk back in the fridge”

Schemas

In the field of Psychology, Schemas have been defined in various ways over the years. Aaron Beck, founder of Cognitive Behaviour Therapy used the term schema to define a collection of negative beliefs, and other researchers and authors (i.e. Piaget) have introduced the idea that individuals experience a mix of adaptive and maladaptive schemas which usually develop in childhood and are elaborated upon throughout ones life.

More recently, Schema Therapy (initially developed by Jeffrey Young) focussed in on early maladaptive schemas. He described them as self defeating emotional and cognitive patterns developing from adverse childhood experiences where the child’s emotional needs were not met. Young’s schemas are grouped into 5 domains:

  • Disconnection and rejection.
  • Impaired autonomy and performance.
  • Impaired limits.
  • Other directedness.
  • Over-vigilance and inhibition.

The disconnection and rejection domain is characterised by a lack of safety and reliability in relationships. In childhood, important others may have treated the individual in a cold and rejecting manner, provided little support, or they could have been unpredictable, uninterested, or abusive. The schemas in this domain are: abandonment, mistrust/abuse, emotional deprivation, defectiveness/shame, and social isolation/alienation.

Individuals who score high in the impaired autonomy and performance domain generally hold a belief that they are incapable of functioning independently. They may have come from a family who were overbearing and didn’t allow sufficient opportunity to develop independence. They may have been repeatedly discouraged or talked down to. The schemas in this domain are: dependence/incompetence, vulnerability to harm or illness, enmeshment, and failure to achieve.

Impaired limits typically manifests as poor boundaries and a lack of responsibility. Individuals who score high in this domain may have difficulty applying consistent effort toward long term goals and may have difficulty working with others. They may have come from a family who provided little supervision or corrective feedback, or may have encouraged the child to believe that they were superior to others. The schemas which fall under this domain are: entitlement/grandiosity, and insufficient self-control/self discipline.

Individuals who score high in the other directness domain push down and repress their own needs while elevating the importance of the needs of others over their own. They may have come from a family where love and acceptance were conditional and the child may have had to suppress their true desires, thoughts, and emotions to gain love, attention, or approval. The schemas associated with this domain are: subjugation, self-sacrifice, and approval/recognition seeking.

Over vigilance and inhibition is the final domain and is characterised by a lack of spontaneity and play. Individuals who score high in this domain may suppress spontaneous feelings and impulses, and may tend to focus on meeting rigid expectations at the expense of happiness, health, and healthy relationships. The family of origin may have been tinged with high demands for performance and obligations. The child may have had to hide their emotions and strive for perfection. The schemas that apply to this domain are: negativity/pessimism, emotional inhibition, unrelenting standards/hyper-criticalness, and punitiveness.

If you would like to explore your own schemas and how they apply to your relationships, I recommend purchasing the self-help book Breaking Negative Relationship Patterns: A Schema Therapy Self-help and Support Book (Stevens and Roediger). A related text which may interest you is Breaking Negative Thinking Patterns: A Schema Therapy Self-help and Support Book (Jacob, vanGenderen, and Seebauer). The latter text has less of a focus on schemas and instead focuses on ‘modes’ which I will cover in a later post.

Of course, self-help texts do not replace good quality therapy with a registered professional. If you would like to explore your schemas further, you can make an appointment at one of the two locations listed on the welcome page of my website: http://www.SQPsych.com.

Communicating Compassionately

All too often, relationships of all kinds can be coloured by disconnection, alienation, and hurt. Loved ones, children, parents, friends, and colleagues can and do fall into negative patterns of communication that cause conflict.

A few years ago, I was thankful to discover Non-Violent Communication (NVC) which helped scaffold my understanding of how to think about the way I am communicating with others, particularly in situations where emotions are running high and it feels that there is a lot at stake. NVC helps us to remember our common humanity and strengthens our ability to remain compassionate, even under trying conditions. There are four parts to the NVC process:

  • Observing
  • Expressing and receiving feelings
  • Expressing and receiving needs
  • Requesting

NVC is about giving and receiving from the heart. It is also about being able to observe our own and others behaviour without evaluating or making judgements. Of course, sometimes we can fall into traps which block our communication and founder of NVC Marshall Rosenberg identified three main types of communication that block compassion: Moralistic Judgements, Making Comparisons, and Denial of Responsibility.

  1. Moralistic judgements imply wrongness or badness instead of recognising there is misalignment in our values and the values of others. Examples of some words that may convey a moralistic judgement are: ” The problem with you is that you are just so selfish”, “He is such a trouble maker”. This type of communication promotes conflict and differentiation rather than harmony and commonality. It is sometime also called blame, insult, put-down, labelling, or criticism.
  2. Comparisons are another form of judgement that alienate us from one another. Comparing ourselves with others is a sure way to make ourselves miserable. Dwelling on differences in physical appearance, intelligence, achievement and so on leads to unnecessary suffering.
  3. Denial of responsibility clouds our awareness that each person is responsible for their own thoughts, feelings, and actions. The way we use speech is important and can displace responsibility. For example: “you have to do it” or “you must stop that” conveys that the individual receiving that message is not in control or responsible for their own behaviour. Similarly, responsibility for feelings can often be misplaced when phrases such as “You make me feel terrible about myself” are used. It is untrue to say that anyone has a direct channel to another persons feelings or can make another person feel a certain way.

The spirit of non-judgement intended by NVC is perhaps best communicated by Ruth Bebermeyer’s lyrics from the song ‘Lazy Man’:

I’ve never seen a lazy man;
I’ve seen a man who never ran
while I watched him, and I’ve seen
a man who sometimes slept between
lunch and dinner, and who’d stay
at home upon a rainy day,
but he was not a lazy man.
Before you call me crazy,
think, was he a lazy man or
did he just do things we label “lazy”?

I’ve never seen a stupid kid;
I’ve seen a kid who sometimes did
things I didn’t understand
or things in ways I hadn’t planned;
I’ve seen a kid who hadn’t seen
the same places where I had been,
but he was not a stupid kid.
Before you call him stupid,
think, was he a stupid kid or did he
just know different things than you did?

I’ve looked as hard as I can look
but never ever seen a cook;
I saw a person who combined
ingredients on which we dined,
A person who turned on the heat
and watched the stove that cook the meat –

I saw those things but not a cook.
Tell me when you’re looking,
is it a cook you see or is it someone
doing things that we call cooking?

What some of us call lazy
some call tired or easy-going,
what some of us call stupid
some just call a different knowing,
so I’ve come to the conclusion,
it will save us all confusion
if we don’t mix up what we can see
with what is our opinion.
Because you may, I want to say also;
I know that’s only my opinion.

If you would like to learn more about how to apply Non-Violent Communication in your own life, you can make an appointment at one of the two locations listed on the welcome page of my website http://www.sqpsych.com.

Cognitive Distortions

Our mind does have some pretty neat tricks. A lot of the time it is very good at categorising, problem solving, and working with information in its different forms. At times though, our mind can lead us down the garden path without us being aware of it. Cognitive distortions are one such way that our mind can perform its neat tricks. When our mind processes information in a distorted way, our thinking deviates from normal rational judgement. In a way, we are mildly disconnected from reality and this disconnection can inadvertently lead us to a pattern of negative thinking, behaviours, and emotions.

Cognitive research has tested and described hundreds of cognitive biases with implications for business practices, social reform, and mental health. Here I want to focus on some of the cognitive biases which have been applied to the treatment of a number of mental health conditions including depression and anxiety.

Cognitive Behaviour Therapy (and related therapies like Schema Therapy/ACT/CFT to a degree) is concerned with cognitive biases characterised by extreme thinking, selective attention, over-reliance on intuition, and self-reproach which can inadvertently lead to increased emotional distress. Several common distortions are regularly referred to and include:

  • Black and white thinking
  • Unrealistic expectations
  • Catastrophising
  • Over-generalisation
  • Mental filter
  • Disqualifying the positives
  • Magnification
  • Minimisation
  • Jumping to conclusions
  • Emotional reasoning
  • Taking things personally
  • Self-blame
  • Name calling (self)

For example, when we become over-reliant on our intuition, we can “jump to conclusions” and make assumptions without facts to support those assumptions. Practically, this can present itself as negative thinking during social situations (mind reading), where we assume that we know what others are thinking about us. In these situations our mind can say things like: ” I know that behind their smiles, they are laughing at me and thinking that I am a fool”. Of course with these types of statements running through our mind unchecked, we are likely to experience a whole lot of negative emotions.

At times, simply noticing what our mind is doing can help us to deal with cognitive distortions. When we can see what our mind is doing and label the process, this can help us to create distance from the content of the thoughts, and reduce the intensity of the emotions. At other times a different approach may be helpful. For the example above, rather than trying to guess what others are thinking, it may be helpful to clarify how the other person is generally thinking and feeling by asking them. Alternatively, some people find it helpful to begin developing a new habit of listing a couple of other possible thoughts and feelings that the other person might be having, and noticing social signals (where the other person is looking, body posture etc.) which are in support of that alternative view.

If you would like to explore your tricky mind and how cognitive distortions apply to you, you can make an appointment at one of the two locations listed on the welcome page of my website: http://www.sqpsych.com.

Human Strengths

At times we can easily become fixated on what is wrong with ourselves and others, and can forget about what is right with us. With some 300 disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, the study of Psychology and Psychiatry are not immune to this phenomenon of negativity, tending to focus on misery and how to get rid of it. Realising that we are getting caught up in our own shortcomings, it may be helpful to shift our perspective to the human strengths, virtues, and personal fulfilment.

At times, strengths seem to be inborn and temperamental, at other times strengths seem to be forged through adversity, while some strengths are cultivated through conscious effort. There also appears to be consistency across cultures about many of the character virtues which are held in high regard in communities at home and abroad. According to the founder of positive psychology, Martin Seligman, there are 6 universal virtues which emerge consistently from philosophy and historical surveys:

  • Wisdom
  • Courage
  • Humanity
  • Justice
  • Temperence
  • Transcendence

Attached to each of these virtues are a number of character strengths. For example, the strengths of wisdom are creativity, curiosity, open-mindedness, love of learning, and perspective. An individual may demonstrate 1 or 2 of those strengths and certain situations provide the conditions for the strength to be demonstrated. For example, courage may be displayed where some danger or adversity is faced, but not during times of safety and ease.

I also see fulfilment our innate human needs as a source of strength. Humanistic Psychologist Abraham Maslow detailed a hierarchy of needs beginning with a broad base of basic needs (i.e. food, water, shelter) and extending to the top of the hierarchy with what he termed as “self- actualisation”.

Maslow’s Hierarchy

From Maslow’s perspective, self-actualisation occurs when basic bodily and ego needs have been fulfilled and one realises their full potential. From Carl Rogers’ perspective, self-actualisation is more of an ongoing process of exploring, maintaining, and enhancing our self-concept through self-reflection and reinterpretation which can help us to heal and grow.

If you would like to learn more about your own strengths and self-concept, you can make an appointment at one of the two locations listed on the welcome page of my website http://www.sqpsych.com.

Personal Values

Our personal values (i.e. honesty, fitness, intimacy) and for some of us our faith, spirituality or religion are important sources of strength and meaning. They are powerful motivators which can help us to tolerate uncomfortable experiences and act in a valued way. When acting in a valued way, our lives become meaningful.

When acting in a valued way, we tend to work toward our goals even when we don’t feel so motivated in the moment. We are proud of our actions, and feel as though we are making progress. There is also congruence between who we want to be, and the actions that we are taking to actually be that person.

When we loose sight of our values, we can spend a lot of time thinking about the past or the future, feel like we are on auto-pilot, different thoughts and feelings seem to get in the way, and we tend to give in easily, pack up, and quit.

It can be helpful to clarify our values and learn to keep them in mind throughout our day to day, and also when making big life decisions. I learned about the importance of values from leaders in the field of acceptance, humanistic, and positive psychology:

  • Acceptance and Commitment Therapy, Steven C. Hayes, Russ Harris.
  • Client-Centered Approach, Carl Rogers.
  • Positive Psychology, Martin E. P. Seligman.

If you would like to learn more about your own values, you can make an appointment at one of the two locations listed on the welcome page of my website: http://www.sqpsych.com.

Human Suffering

As human’s, it seems that we are bound to suffer at one time or another during our lives. Uncomfortable experiences seem to be part of the human condition. We experience emotions and bodily sensations that are unchosen and often unwanted. Of course, when something is unwanted, our first reaction is to want to stop or change it. Unfortunately, with emotions and bodily sensations trying to struggle with them only seems to make matters worse and increase our suffering.

Trauma is also important to consider when we are talking about suffering. When we experience something traumatic, that experience seems to change us, and this includes how our nervous system is ‘wired’. The nervous system not only includes the brain, but also stretches right throughout the body from the tips of our toes to the tops of our heads and the tips of our fingers. In psychology and related fields we have learned that trauma is held in the body. At times our body and brain can send us accurate signals to engage in self-protection, while at other times ‘faulty’ warnings can occur.

I learned about these aspects of human suffering from several leaders in the field of acceptance, compassion, and trauma based therapies and research:

  • Acceptance and Commitment Therapy, Steven C. Hayes.
  • Compassion Focussed Therapy, Paul Gilbert.
  • Trauma and the Body, Bessel Van Der Kolk.
  • Cognitive Behavioural Therapy and Mindfulness, John Briere.
  • Sensorimotor Psychotherapy, Pat Ogden.

If you would like to discuss your relationship with uncomfortable experiences and how you interact with them, you can make an appointment at one of the locations listed on the welcome page of my website: http://www.sqpsych.com.