oThis is a technical memo for therapists who use a technique I developed years ago called the Individual Downward Arrow Technique. The goal of this technique is to uncover each patient’s (client’s) Self-Defeating Beliefs (SDBs), such as Perfectionism, Perceived Perfectionism, or the Brushfire Fallacy. I developed this memo for my Tuesday evening TEAM-CBT group at Stanford following a session practicing this technique earlier in the week.

Why would a therapist want to uncover SDBs? Cognitive Therapists work with (at least) two types of cognitions that can cause emotional distress. First, Negative Thoughts happen in the here and now and only cause emotional distress at specific moments in time. Let’s say you have public speaking anxiety, and you’re about to walk up to the podium. You are probably telling yourself things like this: “I’ll blow it. My mind will go blank. I’ll make a total fool of myself. People will laugh at me and judge me.” These kinds of Negative Thoughts happen in there here-and-now, when you are feeling anxious or depressed. The Negative Thoughts are usually not present when you are feeling happy and confident.

The SDBs represent a second category of cognition. These belief systems represent some of our core values, and they are always there in the background, whether or not we are upset. So, for example, you may have a belief called Perceived Perfectionism, thinking that people will not accept, respect or love you if you screw up or appear vulnerable. Or you may have the Approval Addiction, thinking you need everyone’s approval to feel happy and fulfilled. Or you may have the Achievement Addiction, basing your self-esteem on your intelligence or accomplishments. There are a great many kinds of SDBs.

The cognitive theory of emotional distress works like this: the combination of a Self-Defeating Belief (such as the Achievement Addiction) plus a negative event (such as screwing up or doing poorly when you give a talk) triggers emotional distress. That’s when you are flooded with negative thoughts and feelings, such as “Gosh, my talk was kind of a dud. People seemed bored. I’m a loser,” etc.

So the SDBs appear to explain the timing and reason for episodes of depression and anxiety.  And if we can pinpoint and change the patient’s (client’s) SDBs, we can not only help the patient to feel better in the here-and-now, but we may also help to prevent painful mood crashes in the future.

In this memo, I discuss the finer points of how to use the Individual Downward Arrow Technique to pinpoint each patient’s Self-Defeating Beliefs. If you are interested, I could address how to change SDBs in a future blog or in an upcoming Feeling Good Podcast.

I will be curious to find out if this type of information is of interest to my readers, so please let me know what you think! If the information that follows is too technical, no problem! I just want to get a feel for what people like and want so I can serve you in the best possible way. Thanks!

David

Tips for Therapists When Using the Individual Downward Arrow Technique

By David Burns, MD*

I would like to thank Daniele Levy, PhD for conceptual and editing help!

What is the Individual Downward Arrow Technique? This technique will help you pinpoint the Individual Self-Defeating Beliefs (SDBs) that make the patient vulnerable to depression and anxiety. For example, the patient may base his or her self-esteem on accomplishments, the so-called “Achievement Addiction,” or may struggle because of Perfectionism, Perceived Perfectionism, Entitlement, or the Approval or Love Addiction. You can find a list of “23 Common Self-Defeating Beliefs” in the Therapist’s Toolkit or my Feeling Good Handbook. The Individual SDBs are often “self-esteem equations,” of the form, “To be a worthwhile human being I need substance X.” Substance X could be great achievement, wealth, love, perfection, approval, or always pleasing others, for example.

To use this technique, draw a downward arrow under a Negative Thought on a Daily Mood Log and ask your patient, “Why would it be upsetting to you if this thought were true? What would it mean to you?” This will trigger a new Negative Thought. Tell the patient to write it down under the arrow and repeat the process several times. The NTs you and your patient generate will lead to the underlying beliefs at the core of his or her suffering.

There are three additional Uncovering Techniques. The Interpersonal Downward Arrow Technique helps you pinpoint the beliefs and attitudes that trigger conflicts and difficulties in the patient’s personal relationships. The What-If Technique helps you pinpoint a core feared fantasy that trigger’s the patient’s anxiety. And the Hidden Emotion Technique helps you bring suppressed hidden problems and conflicts to the patient’s conscious awareness.

Here are some important tips to keep in mind when using the Individual Downward Arrow technique:

SET UP

1. Always start with a Negative Thought (NT) from a Daily Mood Log when doing the Downward Arrow Technique. Don’t do the Downward Arrow Technique for some problem the patient has, or based on some emotion the patient has.
2. Both patient and therapist must be writing during the Downward Arrow Technique. Usually, I use a blank sheet of paper, because the DML gets too filled up with the chain of NTs. But keep in mind that your blank sheet of paper is really an extension of the NT column on the DML.
3. Remember to be compassionate when doing the Downward Arrow, and not overly harsh or intellectual. For example, if the patient says, “That would mean I was a total failure,” you can say, “Of course, that would be pretty painful for almost anyone to feel like you were a total failure, but I’m wondering what it would mean to you? Why might that be upsetting you?”
4. If the patient becomes tearful, perhaps recalling a painful childhood memory during the Downward Arrow process, put your techniques on the shelf and empathize, encouraging your patient to vent and open up. These moments can be quite important to the patient.

WORDING OF NTs

5. Convert rhetorical questions into statements. “Why am I so screwed up?” can become “I’m screwed up,” or “I shouldn’t be so screwed up.”
6. When doing a Downward Arrow from a “Should Statement,” such as “I shouldn’t have left my husband,” you can say, “Let’s assume it’s true that you shouldn’t have left your husband, but you did. What does that mean to you? Why is that upsetting to you?”
7. Never put emotion words or descriptions of upsetting events in the NTs column when doing the Downward Arrow. Instead, ask for the NT that is associated with the emotion or event. For example, if the patient says, “Then I’d feel ashamed,” you can say, “What is the NT that would make you feel ashamed? What would you be telling yourself?”
8. If the patient comes up with a wish or a positive thought when you’re doing the Downward Arrow Technique, you can convert it to an NT. For example, let’s say a patient has this thought about dropping out of school: “I’ll be letting my parents down. I’ll be a disappointment to them.” Then you ask, “If this were true, what would it mean to you? Why would it be upsetting to you?” The patient might say, “Well, I really want my parents to be proud of me.” You can easily convert it by saying, “So let’s assume you really want your parents to be proud of you, but they’re actually disappointed in you for dropping out of school. What would that mean to you? Why would that be upsetting to you?”

PROBING

9. If the patient says, “I don’t know,” use Multiple Choice Empathy. For example, the patient may have the NT, “Then I’d be all alone forever,” when you are doing the Downward Arrow Technique, but when you ask, “And what would that meant to you, and why would that be upsetting to you,” he or she might say, “I don’t know.” Using Multiple Choice Empathy, you might say, “Of course, probably no one would want to be alone forever, but it could mean different things to different people. Some people might think that if they’re alone, they can’t survive, or if they’re alone, it means they’re unlovable and worthless, and others might think it’s impossible to feel happy and fulfilled when you’re alone. Do any of those possibilities ring true for you?”
10. You can also use the “Man (or Woman) from Mars” approach if the patient says, “I don’t know why that would be upsetting for me.” Let’s say the patient comes up with this thought during the Downward Arrow Technique: “That would mean I failed,” but can’t explain why failure would be upsetting or bad. You can say, “Let’s assume I’m a man (or woman) from Mars, and I don’t know how things work here on the surface of the earth. So I might ask you to explain why failure is considered a negative thing here on the earth. What happens to people who fail at something?” This will usually make it easier for the patient to continue the Downward Arrow Chain.
11. Using Bracketing when the patient cycles back and forth between two NTs. For example, the patient might say, “Then I’d be a failure,” followed by “Then no one would love me,” followed by “Then I’d be a failure,” etc. You can bracket them in this way: “And suppose you were a failure, and no one loved you. What would that mean to you? Why would that be upsetting to you?”

GOAL CONSIDERATIONS

12. The purpose of the Downward Arrow Techniques is uncovering the patient’s SDBs, not change. You can change SDBs, but change is not the goal when you are doing an Uncovering Technique. If you think about an NT on a Daily Mood Log, most of the time we are doing horizontal arrow techniques. In other words, we want to move from the NT column on the left to the Positive Thought (PT) column on the right, and this involves trying to challenge and crush the NT so that emotional change will suddenly happen. In contrast, when you use a downward arrow technique, you are drilling down deeper into the patient’s psyche to uncover the beliefs that give rise to the negative thoughts and feelings. You are moving to a deeper level.
13. Sometimes, a patient will begin to recognize the absurdity of the NTs when doing the Downward Arrow, and will begin to come up with convincing and effective Positive Thoughts (PTs). This is okay, and you can encourage the patient to write the PTs in the PT column on the Daily Mood Log.
14. The Self-Defeating Beliefs are the logic behind the negative thoughts on the Downward Arrow Chain, since the thoughts do not logically follow from one another. For example, a psychologist’s favorite patient unexpectedly committed suicide, and one of his NTs was: “I should have seen this coming. I should have known he was suicidal.” His next thought on the downward chain was, “This means I’m a failure and a fraud.” Notice that the second thought does not follow logically from the first thought, but the SDB that links them is Perfectionism. His third thought was, “My colleagues will judge me and reject me.” Again, this does not follow logically, and the SDB that links them is Perceived Perfectionism—namely, the belief that others will not accept, love, or respect him if he is vulnerable, or human, or makes a mistake.

* Copyright © 2017 by David D. Burns, MD

If you are reading this blog on social media, I appreciate it! I would like to invite you to visit my website, http://www.FeelingGood.com, as well. There you will find a wealth of free goodies, including my Feeling Good blogs, my Feeling Good Podcasts with host, Dr. Fabrice Nye, and the Ask Dr. David blogs as well, along with announcements of upcoming workshops, and resources for mental health professionals as well as patients!

Once you link to my blog, you can sign up using the widget at the top of the column to the right of each page. Please forward my blogs to friends as well, especially anyone with an interest in mood problems, psychotherapy, or relationship conflicts.

Thanks! David