Cognitive behavior therapy
John Winston Bush, PhD
New York Institute for Cognitive and Behavioral Therapies
Just what is CBT? How does it work?
Cognitive behavior therapy* combines two very effective kinds of psychotherapy — cognitive therapy and behavior
therapy.
Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to
them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to
calm your mind and body, so you can feel better, think more clearly, and make better decisions.
Cognitive therapy teaches you how certain thinking patterns are causing your symptoms — by giving you a distorted
picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking
you into ill-chosen actions.
When combined into CBT, behavior therapy and cognitive therapy provide you with very powerful tools for stopping
your symptoms and getting your life on a more satisfying track.
CBT is active therapy
In CBT, your therapist takes an active part in solving your problems. He or she doesn't settle for just nodding wisely
while you carry the whole burden of finding the answers you came to therapy for.
You will receive a thorough diagnostic workup at the beginning of treatment — to make sure your needs and problems
have been pinpointed as well as possible.
This crucial step — which is often skimped or omitted altogether in traditional kinds of therapy — results in an explicit,
understandable, and flexible treatment plan that accurately reflects your own individual needs.
In many ways CBT resembles education, coaching or tutoring. Under expert guidance, as a CBT client you will share in
setting treatment goals and in deciding which techniques work best for you personally.
Structured and focused
CBT provides clear structure and focus to treatment. Unlike therapies that easily drift off into interesting but
unproductive side trips, CBT sticks to the point and changes course only when there are sound reasons for doing so.
As a CBT client, you will take on valuable “homework” assignments to speed your progress. These tasks — which are
developed as much as possible with your own active participation — extend and multiply the results of the work done in
your therapist's office.
You may also receive take-home readings and other materials tailored to your own individual needs to help you continue
to forge ahead between sessions.
What else is different about CBT?
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Most people coming for therapy need to change something in their lives — whether it's the way they feel, the way they
act, or how other people treat them. CBT focuses on finding out just what needs to be changed and what doesn't — and
then works for those targeted changes.
Some exploration of people's life histories is necessary and desirable — if their current problems are closely tied to
“unfinished emotional business” from the past, or if they grow out of a repeating pattern of difficulty. Nevertheless, 100
years of psychotherapy have made this clear . . .
Past vs. present and future
Focusing on the past (and on dreams) can at times help explain a person's difficulties. But these activities all too often do
little to actually overcome them. Instead, in CBT we aim at rapid improvement in your feelings and moods, and early
changes in any self-defeating behavior you may be caught up in. As you can see, CBT is more present-centered and
forward-looking than traditional therapies.
The levers of change
The two most powerful levers of constructive change (apart from medication in some cases) are these . . .


Altering ways of thinking — a person's thoughts, beliefs, ideas, attitudes, assumptions, mental imagery, and ways
of directing his or her attention — for the better. This is the cognitive aspect of CBT.
Helping a person greet the challenges and opportunities in his or her life with a clear and calm mind — and then
taking actions that are likely to have desirable results. This is the behavioral aspect of CBT.
In other words, CBT focuses on exactly what traditional therapies tend to leave out — how to achieve beneficial change,
as opposed to mere explanation or “insight.”
CBT: The therapy with by far the most research support
CBT has been very thoroughly researched. In study after study, it has been shown to be as effective as drugs in treating
both depression and anxiety.
In particular, CBT has been shown to be better than drugs in avoiding treatment failures and in preventing relapse after
the end of treatment. If you are concerned about your ability to complete treatment and maintain your gains thereafter,
keep this in mind.
Other symptoms for which CBT has demonstrated its effectiveness include problems with relationships, family, work,
school, insomnia, and self-esteem. And it is usually the preferred treatment for shyness, headaches, panic attacks,
phobias, post-traumatic stress, eating disorders, loneliness, and procrastination. It can also be combined, if needed, with
psychiatric medications. (See next section.)
No other type of psychotherapy has anything like this track record in outcomes research.
What about drug treatment?
CBT is usually employed by itself, without psychiatric drugs. For some people, however, drug treatment is needed to
obtain a partial reduction in symptoms before CBT can be fully effective. Usually, though not always, it is preferable to
try CBT alone before prescribing medications. This is for several reasons:
Benzodiazepine drugs such as alprazolam (Xanax), plus certain other types of tranquilizers, can be habit-forming if taken
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over a long time or in high doses. This is a complication that needs to be avoided if possible. Despite their reputation as
“wonder drugs,” antidepressants such as amitryptaline (Elavil) and fluoxetine (Prozac) work only about 65% of the time.
MAOI drugs (e.g., Nardil) carry a risk of hypertensive crisis, stroke or even death if common foods or beverages
containing tyramine are unintentionally consumed. Finally, the mood stabilizer lithium carbonate can produce toxic
reactions unless it is very carefully monitored.
In addition, research studies have revealed these other facts about drug treatment for depression and anxiety:




CBT and well-chosen drugs, when each is used alone, are about equally effective during the period of active
treatment.
Adding drug treatment to CBT is not likely to get better results than using CBT alone (except in special cases
such as the one described above).
Treatment failure is more likely when drugs are used, typically because of side effects.
Relapse after the end of treatment is more likely when only drugs have been used. This is believed to be because
drugs, unlike CBT, do not encourage the development of valuable coping and emotional management skills.
Questions that are being raised about antidepressant drugs
In addition, a number of questions have been raised about antidepressant drugs — which are increasingly being
prescribed for anxiety conditions as well:






Whether widespread beliefs about their effectiveness are scientifically justified.
The side effects and withdrawal symptoms they can produce.
Their use with children.
Their safety, especially when used in combination with other psychoactive drugs.
The theories about depression that support their use.
Whether they really are as likely to help as well-chosen forms of psychotherapy.
If you would like to see a summary of a recent scientific article reviewing research on the antidepressants, click here. To
see a recent Boston Globe article on the same topic, click here.
CBT is usually brief
Most CBT patients are able to complete their treatment in just a few weeks or months — even for problems that
traditional therapies often take years to resolve, or aren't able to resolve at all.
Meanwhile, for people with complex problems, or who are forced to live in adverse conditions beyond their control,
longer-term treatment is also available.
(See discussion of factors affecting treatment length.)
How often will I be seen?
The answer to this question depends on your individual needs, your insurance plan, and the way your own therapist
prefers to work.
As a rule, however, most people can expect to begin their treatment with weekly visits.9
A few — particularly if they are in crisis — may begin with two or more sessions a week until their condition is stabilized
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enough that they can safely come only once a week.
What happens further on in treatment?
Again, the answer depends on how you are progressing, and on your therapist's and your own preferences. These are
among the options that are often recommended . . .




Individual sessions every other week or monthly, combined with weekly group therapy meetings.
Individual sessions every other week or monthly, without participation in group therapy.
A planned break of several weeks, followed by resumption of weekly individual sessions for a period of time.
A trial termination of therapy — with the option of resuming if the need develops. Quite often, a follow-up
session or phone contact is scheduled for a future date.
Do it when you need it, and not
when you don't
In addition, most CBT practitioners subscribe to the principle of intermittent brief psychotherapy, as and when needed.
In this treatment model — espoused by Dr. Nicholas Cummings, a world leader in therapeutic advancement and former
president of the American Psychological Association — you don't “go into therapy” and stay for year after year,
regardless of whether you're making significant progress or not.
Instead, you consult your therapist when there's a problem you need professional help with — and not in between. After
all, isn't this sensible approach the one you follow with your physician, your dentist, your attorney or accountant, and all
those other professionals?
How can I find a CBT professional?
If you are in or near New York City, you can call the Cognitive Therapy Center of Brooklyn (the private practice of John
Winston Bush, PhD). The phone number is 718 636-5071; if you need to leave a message, please use voice mailbox 1. Or
if you prefer, you can send an e-mail inquiry to him at jwb@alumni.stanford.org from CBT Web site visitor. For
complete information about Dr. Bush, see his curriculum vitæ (highfalutin academic name for résumé) on this site.
Otherwise, you might want to consult the Center's national list of CBT providers.
Now, to learn more about CBT . . .
These have been the essentials. To understand more of how CBT works — and why it works so well — click the
following link to read A fuller explanation of CBT.
The cognitive side of CBT
Perhaps this will help make it clear. You must have noticed that when you are experiencing an emotion, your body feels
different. This is because you're sensing certain distinctive changes in your internal physiology. It's no accident that the
word "feeling" can be a synonym for "emotion." In other words (to simplify things a bit) . .
To have an emotion is to feel the physical (bodily)
consequences of our thoughts.
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Imagine the following situation:
A friend is due to meet you for dinner at your house at 7:00. But it's now past 8:00, and there's been no sign of her — not
even a phone call. How are you going to feel about this?
Well, as this diagram makes clear, there's more than one possible answer:
What you think
Friend is late for
dinner
How you feel
What you do
"She might have been hurt on
the way here."
Worried or anxious
Call hospital ERs to find out
if she's there
"She didn't bother to let me
know she was delayed."
Annoyed or angry
Chew her out, or act chilly,
when she does show up
"It doesn't matter to me
whether people are on time."
Indifferent
Nothing in particular
"I needed the time to fix the
house up anyway."
Relieved
Relax and enjoy yourself
Now of course there are ways not shown in the diagram in which someone might interpret a friend's being late, and
different ways — as a result — in which he or she might react emotionally and behaviorally.
Note also that your thoughts about your friend's lateness don't affect just your feelings — they can also influence the
actions you take.
And while it might seem silly to consult a psychotherapist over nothing more than a dinner date, the basic principle is
exactly the same when it comes to major and more complex problems.
As the philosopher Epictetus said almost 2,000 years ago:
"The thing that upsets people is not what happens
but what they think it means."
People — and I mean all people, not just patients — routinely distress themselves and others with arbitrary
interpretations of what is going on. Sometimes this is done out of blind habit, or under the influence of a bad mood or
bodily discomfort; sometimes it happens for quite other reasons. Challenging, and at times changing, one's doubtful
interpretations of events is much of the cognitive work of CBT.
It's important not to get this confused with the ever-popular practice of "positive thinking." In CBT the goal is accurate
and rational thinking — the kind that is based as much as possible on logic and the available facts. Most of the time this
does result in a more positive outlook — but there are also times when its value lies in correcting an undesirably rosy
view of things.
And now for the other side . . .
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So far, we've been looking at how our thinking influences our feelings and behavior. Before going on, however, we
also need to look at the converse — how our feelings and behavior influence our thinking.
For a wide-ranging review of the first part of this vital topic, see Stanford psychologist Gordon Bower's speech and
monograph, Emotion and Social Judgments. (File size is 55KB, but well worth it — there's enough food for thought in
this paper to keep you topped up for weeks.)
If something happens to which you automatically and reflexively react with fear or anxiety, your thoughts will tend to
be about danger and the consequences of being harmed. Similarly, if your instant reaction to an event is to feel angry or
sad or happy — and especially if you also act on your feelings — your thoughts (including your recollections of the
past and your vision of the future) will be biased in the same direction
Emotional reactions arise chiefly in a region of the brain called the limbic system, which is very fast-acting and can
respond to events on the basis of quick-and-dirty impressions. This nimbleness of response has survival value in some
situations — such as noticing a fast-moving object that could be a car or truck approaching as you cross a street.
But on other occasions — such as complex situations where you need to call on more of your accumulated knowledge
and experience, speed can be a disadvantage. The more complete information you need at such times has to be
processed by the lateral prefrontal cortex of your brain — which gets into gear about half a second later than your
limbic system. This short delay is often enough that your thinking, under the influence of an automated emotional
reaction, heads off in a biased direction that you may come to regret.
In instances like these, the influence of thinking on emotions can be one of sustaining or amplifying an emotion as
opposed to initiating it. (To see how this works, remember some occasion when something made you hopping mad, and
you then fed the feeling with minutes or hours of angry thoughts — only to discover later on that there had simply been
a misunderstanding.)
In practice, treating this kind of problem clinically involves methods traditionally associated, not with cognitive
therapy, but with behavior therapy. To which we now turn.
The behavioral side of CBT
You've probably heard about the Russian physiologist Ivan Pavlov. The one who taught dogs to salivate when they
heard a buzzer. Since we're going to be talking about Pavlov's contributions to psychotherapy, you may as well know
that he looked exactly like this guy with the cool Edwardian beard . . . .
Much, though far from all, of behavior therapy derives from Pavlov's demonstration that events occurring closely
together in time are likely to be stored in the brain in a sort of mental package. Because Pavlov set off the buzzer just as
he was about to give the dog some food, the buzzer and the food became associated with each other. As a result, after a
while the dog began salivating when he heard a buzzer — whether he was given food or not.
The next thing Pavlov discovered was that if he sounded the buzzer too often without coming through with some food,
the dog no longer salivated just because there was a buzzer buzzing. This is called, in the jargon of behavior theory,
"extinction." It refers to the fact that a conditioned reaction — in humans as well as dogs — can become substantially
overridden if it is no longer "reinforced."
(Reinforcement, in the Pavlovian learning model, means that some event like the sounding of a buzzer — which doesn't
naturally bring forth a reaction such as a salivating — is experienced at the same time as something that does, such as
the sight or smell of food. When this happens, the event can become an artificial cue or signal that triggers something
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resembling the natural response.)
P.S.: Recent developments in learning theory — corroborated by recordings of dopamine-connected neurons of the
brain's "reward system" — suggest that Pavlov's dogs didn't learn to salivate just because they heard the buzzer at the
same time as they received food. They learned it when the arrival of food came as something of a surprise, since they
hadn't previously expected buzzers to be a signal for food. Makes sense: if they'd already known about the connection,
what would there have been for them to learn?
A couple of practical examples
For example, if you are deathly afraid of riding in elevators, we can usually extinguish that fear if you are willing to
crank up your courage and take one elevator ride after another until you are no longer unreasonably afraid. It works
because your conditioned fear reaction is not being reinforced — that is, the elevator doesn't fall or get stuck for hours.
(On the other hand, if you give in to the fear and avoid elevators, you can pretty much count on spending the rest of
your life being afraid of them.)
Or, to give another example, let's imagine that you become depressed following a setback such as the loss of a loved
one or the collapse of your efforts to achieve some valued goal.
You may feel that it's useless to try to live a normal life, since your energy and ability to enjoy things seem to have
vanished. You probably expect that pursuing your goals will merely lead to disappointment, frustration or failure — in
other words, you have a sense of futility. Acting on these feelings, you drop out of your usual activities and social
relations. The result: your life becomes even more constricted and unrewarding, and your morale goes still deeper into
the hole.
Getting back to normal
What we are likely to do in CBT is move you gradually back towards leading a normal life, without waiting for it to
feel as good as it once did. If you diligently follow this plan, the renewed contact with your friends, family and regular
activities should eventually bring your mood and feelings back to normal. This is because before you became
depressed, your usual activities and relationships were associated with more energy and enjoyment than you are feeling
now. We are trying to take advantage of those connections as a means of bootstrapping your morale to a more
satisfactory level.
(You might like to see the report of a 1996 study of treatment for depression suggesting that this kind of behavioral
intervention may be as effective as full-scale cognitive behavior therapy for depression.)
Other behavioral aspects of CBT have nothing to do with Pavlov or "conditioning" of any kind. For instance, we often
work with patients to experiment with taking some action that is likely to prove beneficial and instructive. Or, right in
the office, to enact (rather than just talk about) an interpersonal or internal conflict, in the manner of Gestalt therapy
"chair work" or psychodrama.
These have been just a few illustrations of the hundreds of behavioral interventions that are possible. But perhaps now
you have at least some feel for the "B" in CBT.
Why cognitive? Why behavioral?
Everyone, including cognitive behavior therapists, understands that emotions and moods are governed by factors in
addition to one's own thinking and behavior. However, as a practical matter virtually the only means of access to our
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moods and emotions are the cognitive and behavioral routes.
In order to voluntarily change how we feel, we have to go about it indirectly, not directly. There is no direct way to
influence our feelings and moods. Brains simply aren't built so as to make this possible.
Now, according to Prof. James Gross of Stanford, a leading researcher in the field of emotion regulation, there are five
points in the generation of an emotion at which it may be possible to exercise deliberate influence:
1.
2.
3.
4.
5.
selection of the situation
modification of the situation
deployment of attention
change of cognitions
modulation of responses
The first, second and fifth of these points are targeted in behavior therapy, the third and fourth in cognitive therapy. As
you no doubt suspect, most of the time some combination of behavioral and cognitive methods is needed.
As an experiment, just try to change whatever mood or emotional state you are in right now . . . . OK, did you succeed?
Then how did you do it? Was it mainly cognitive, mainly behavioral, both — or neither one?
What you did
Mainly
Cognitive
Mainly
Behavioral
You thought or imagined something that would support the mood or feeling you
wanted
You called up a memory of a time when you felt that way
You redirected your attention to other thoughts, images or activities
You performed some physical action, such as walking around the room or working
out
You meditated, or did a deep-breathing or relaxation exercise
You talked to someone, perhaps trying to get them to do something that would
change how you felt
You hypnotized yourself, or got some else to hypnotize you
You took a drink, smoked a cigarette, played some music, or popped a Valium
No, what I did was:
?
?
If you did something that you believe was a direct, not an indirect way to change your feeling state, please send an email to me using this link. I'd like to know what you came up with.
Finally, a word about one of the behavioral methods listed above — trying to get other people to change their thinking
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and behavior:
Inducing other people to change their minds, or to act differently, can do wonders for how one feels. However, in
practice it is often easier — and can be more satisfying in the long run — to alter one's own thinking and behavior. And
in any case the main obstacle to influencing others to behave as we would like can easily be our own thinking and
behavior.
For here is the central secret of behavior modification:
In order to modify somebody else's behavior,
you first have to modify your own.
In other words, if you keep on doing the same thing, you'll most likely get the same result. Same old --> same old -->
same old.
Hey! Whatever happened to . . .
. . . Dreams?
Some cognitive behavior therapists (including myself) do in fact work with patients' dream recollections. After all,
research has demonstrated that cognition of a sort can go on outside of awareness.
But the "cognitive unconscious," as it is called in experimental psychology, differs radically from the Freudian version.
And Freud's claim to have uncovered the secrets of dreaming was sheer chutzpah — there were so many interpretive
wildcards in his published case histories that it is a wonder they were ever taken seriously.
Dreams sometimes do point to thoughts — and the emotions associated with them — in ways that are therapeutically
useful, and might go unnoticed otherwise. And sometimes they don't. Their value is real but in general rather limited,
and certainly doesn't justify the central role they are given in psychoanalysis and its derivatives.
. . . My horrible childhood?
If you have good reason to think your childhood was horrible, it may indeed have had something to do with your need
for therapy now. But people can develop psychiatric symptoms for other reasons, and not all of them are readily
explainable. Moreover, there are people whose childhoods were perfectly appalling — yet they weren't severely
affected. (This can happen if they were lucky enough to have been born with genes for a hardy nervous system — or if,
despite having a messed-up family, they got involved with sane and supportive peers.)
The point is that every problem must have begun somewhere, and discussing how it began may or may not be helpful
in helping to overcome it. Some patients profit from a certain amount of reminiscing and emoting about childhood
events, while for others it is largely a waste of time.
Quite often, in fact, thinking and talking about past troubles turns out to be downright harmful. It can lead to emotional
pain that serves no useful purpose. It can lower your stress threshold so that you make mistakes that could have been
avoided. And it can divert your attention to past events about which nothing can any longer be done — at the expense
of your present situation and the opportunities it offers for constructive change.
In CBT, if childhood events are given much attention, the point is not usually to explain today's predicaments in terms
of the past. This exercise has proven to be of limited value therapeutically. The chief value (when there is any) in going
over disturbing memories is to identify repeating patterns that can give the therapy more focus and make it more
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efficient.
A second goal, for some people, would be to provide "exposure without reinforcement" — i.e., habituation of painful
emotions that serve no good purpose and are undermining your efforts to lead a good life. As part of this process,
troubling events that you have not yet talked freely and reflectively about ("unfinished business") can be put into
perspective, so that they no longer act as a drain on your mental and physical resources.
A further difficulty with memories of childhood is that they aren't necessarily accurate, let alone unbiased. Memory is a
tricky thing, particularly when strong emotions are involved. Therapy needs as much as possible to be grounded in the
truth, and too much reliance on memories of the past — especially the remote past — can result in countertherapeutic
distortions.
. . . Id, ego and superego?
Actually, if you go back and read the German, you will discover that Freud's words were das Es, das Ich and das
Überich. English being a Germanic language, these terms would better be translated as the It, the Me and the Over-me.
But James Strachey, Freud's first English translator, thought he had to drag Latin into it, even though his native German
was good enough for Freud himself.
Goes to show what happens when you let one of that Bloomsbury crowd have the assignment.
However you translate the terms, they stand for extremely broad categories of mind and behavior. So broad, in fact, as
to be essentially useless. It's no wonder that a stock joke in psychology goes like this:
Q. What is a psychoanalytic diagnosis?
A. It is a way of describing the patient's problems such that absolutely nothing can be done about them. And to do this
will take several years at three times a week.
. . . The couch?
There is a couch (brown) in my office. Its uses are, in order of importance . . .
1st
For people to sit on.
2nd
To fill that otherwise empty-looking spot in the room.
3rd
For people to lie on while I teach them "progressive relaxation."
4th
For doing occasional hypnotherapy.
5th
(and last)
For a few minutes — not a whole hour — of free association or something resembling it.
. . . The inferiority complex?
Most people have at least a touch of it. (This was Alfred Adler's idea, not Freud's.)
And most of them don't. (Freud was vain enough not to have one, so he and Adler fought about it.)
. . . The obligatory picture of Freud on the wall?
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By now you have doubtless decided that I don't have one of those famous totems in the office. Until recently you'd
have been right. But now there's a picture (see below) that does my feelings justice.
(The picture is of Freud's statue being installed on the campus of Clark University in Worcester, Massachusetts, where
Freud gave his only American lectures. And yes, several members of the Psychology faculty objected to the monument
— but they lost the argument to the university's president, who thought it would lend prestige to the institution, i.e.,
help him raise money.)
To give the man fair credit, it has to be said that he was the first person to make psychotherapy a popular subject.
However, there is not very much more to be said in his behalf.
Freud's celebrated case studies have turned out to be largely inventions of his own imagination. He was a master of
sophistry, self-deception and salesmanship. He indulged in unfettered and highly subjective speculation — and
proclaimed his conjectures to be laws of human nature. And he developed a cult-like following that persists to this day.
As Nobel-winning scientist Sir Peter Medawar put it:
"Psychoanalysis is the most stupendous confidence trick of the 20th century."
(For a comprehensive critique of Freud and psychoanalysis, you might want to read Frederick Crews's book,
"Unauthorized Freud: Doubters Confront a Legend." There are many other books in this genre, but for most people
Crews's is the best place to start. You can order a copy from Amazon.com by clicking on the "Bookstore" link in the
Table of Contents. Or, come to think of it, you can order it right from here. But first bookmark this page so you can get
back here easily, because as you will see below, there's more to come that's worth your reading and thinking about.)
In short, far from advancing clinical psychology and psychiatry, Freud set them back by several decades. And that is
why I've got Ivan Pavlov's picture on my office wall, but until the one you see here came along, not his.
This is not to say that people don't ever benefit from psychoanalysis and its latter-day derivatives (usually called
"psychodynamic therapies"). They sometimes do — even quite gratifyingly at times. After all, even though Freud was
often appallingly wrong, many intelligent, well-motivated people who've come after him have paid attention to their
clients and thought carefully about what was going on.
(If you'd like to see psychoanalysis and CBT directly compared, click here to see an interesting excerpt from Davison
and Neale's leading textbook, Abnormal Psychology, 8th edition.)
The problem is that they so often come up with, or adopt and apply, theories that they personally accept but are
seriously flawed — or that might conceivably be sound but are not based on the kind of scientific evidence that justifies using
them routinely and with confidence. As a result, except for people who respond unusually well to the low-structure, discursive,
speculative and historically-focused style of psychodynamic therapy, even those who benefit from it may end up spending a lot of
time and money they didn't need to.
I know this from long and toilsome experience — I was trained in psychodynamic therapy and practiced it for years. I
didn't give up on it quickly or easily, and in my struggle to find something better, invented a primitive form of CBT
myself. Then I discovered, by reading research reports I'd overlooked before, that it wouldn't be necessary. The wheel
had already been invented. (Too bad about that Nobel I was dreaming of, but life does go on. Sigh.)
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Modifying Thoughts: The Cognitive Therapies
Rational Emotive Therapy
Description
ABC model of emotion.
Activating events
Beliefs (Thoughts)
Consequences (Emotional or behavioural)
Model of Treatment
Dispute Irrational Beliefs
Emotional & Behavioural Consequences are Positive

Socratic dialogue
Method
Goals of RET:




Persuade client that a RET analysis of problem is useful
Identify most important irrational beliefs underlying the present complaint
Show client how to dispute irrational beliefs
Generalise learning so the client can serve as own RET therapist
Identifying A-C connections
Identify B’s
1. I must have sincere love and approval almost all the time from all the people I find significant.
2. I must prove myself thoroughly competent, adequate, and achieving; or I must have real competence or talent at
something important.
3. People who harm me or commit misdeeds are bad, wicked, or villains and that I should blame, damn, and punish
them.
4. If life doesn’t go the way I would like, life is terrible, awful, horrible, or catastrophic.
5. Emotional misery comes from external pressures and that I have little ability to control my feelings or rid myself
of depression or hostility.
6. If something seems dangerous I must become terribly occupied with it and upset about it.
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7. It is easier to avoid facing life’s difficulties and self-responsibilities than to undertake some rewarding forms of
self-discipline.
8. My past remains all-important and because something has influenced me strongly it has to keep on determining
my feelings and behaviours today.
9. People and things should turn out better than they do and that I have to view it as awful and horrible if you do
not quickly find good solutions to life’s hassles.
10. I can achieve happiness by inertia and inaction or by passively and uncommittedly enjoying myself.
11. I must have a high degree of order or certainty to feel comfortable or that I need a supernatural power upon
which to rely.
12. My global rating as a human and my general worth and self-acceptance depends upon the goodness of my
performance and the degree that people approve of me.
(From Ellis, 1977)
"What is the evidence for what you thought?"
"What is the effect of thinking the way you do?
Look for:




Awfulising
I can’t
Musturbating
Damning
Beck
Description
Cognitive Events:
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Depression & anxiety arise from negative automatic thoughts
Automatic = appear to occur involuntarily and not easily dismissed by the client
Cognitive triad
Cognitive Processes
Transform & process environmental stimuli
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Selective abstraction
Overgeneralisation
Dichotomous thinking
Personalisation
Cognitive Structures
Stable characteristic cognitive structures (schemata) that render people vulnerable to anxiety or depression.
Method
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Identify automatic thoughts: monitor
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Ask to identify ATs when there is an abrupt shift in mood in the session
Use evocative role-plays of difficult situations in the client’s life
Engage in "think aloud" techniques to demonstrate one’s own ATs.
Don’t insist thoughts precede emotions
Records
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Activating event
Emotion (0-100)
Automatic thought
Degree of belief (0-100).
Challenge using:
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Evidence
Alternative
Implications
Errors
Methods for focussing on the content of cognitions:
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Downward arrow:
Attend to global words
Inquire about client’s explanations of negative or positive moods.
Attend to self-referent thinking.
Methods for focussing on the form of cognitions


Determine most typical cognitive bias and.
Note ATs that are strongly associated with intense emotion. May be more central.
14
What is Cognitive Therapy?
Robert Westermeyer, Ph.D.
The word "cognitive" or "cognition" means "to know" or "to think". Therefore, cognitive therapy is viewed as a
"psychological treatment of thoughts." Simply, cognitive therapy operates under the assumption that thoughts, beliefs,
attitudes and perceptual biases influence what emotions will be experienced and also the intensity of those emotions.
Cognitive Therapy was pioneered by Aaron Beck, M.D. for the treatment of depression. Dr. Beck and other researchers
have developed methods for applying cognitive therapy to other psychiatric problems, such as panic, anger control
problems and substance abuse. This form of therapy has received considerable research support, especially with regard
to depression.
The view that our thoughts influence our emotions and behavior is hardly new. In fact, the origins of this idea can be
traced back to the Stoic philosophers, namely Epictetus, who wrote, "Men are disturbed not by things, but by the view
which they take of them."
To illustrate this point, imagine you are asleep in bed and you are awakened by a loud crashing sound from downstairs.
How will you feel if you believe that the crash was an intruder? Probably pretty frightened and anxious, right? Now
imagine that you suddenly remember that you just acquired a new kitten that has been knocking over just about
everything in sight. How might you be feeling then? Certainly not frightened or anxious; rather, you might be angry or
even disappointed about the vase.
The nature of our feelings is largely determined by the way that we think. In the above example the feeling (frightened
or angry) was solely dependent on how the event (crashing sound) was construed.
Depression is a mood state that can be brought upon by overly negative interpretations of events. For example, imagine
two people experiencing the break up of a relationship. Imagine that both of them view themselves and the relationship
in different ways. One person conceptualizes the relationship as evidence of his worth as a person and the break up,
therefore, as evidence that he is worthless and unlovable. Further he views the break-up as being caused by his
unlovable characteristics. The second person views the relationship as a very important part of his life. However, it does
not represent his sum total worth. The second person views the break up as due to mutual incompatibility. Which of
these two people would be more likely to experience depressed mood secondary to the break up? Probably the former,
right? The break-up was construed in this as due to a flaw in his character, and since his worth was contingent on being
in a relationship with that partner, the break up affirmed his belief in himself as a worthless failure.
Self-debasing beliefs like these lead to negative emotions like depression and anxiety. The second person didn't deny
that the relationship was important. He may feel sad and frustrated after the break up, but probably will not sink into a
clinical depression. This is because his construction of the break up was realistic and non-self-punitive.
Depression has many causes; biological changes can cause depression, rigid negative attitudes about oneself can cause
depression, catastrophic events can cause depression. But one thing occurs after onset that is common to depression
regardless of its etiology: negative thinking. Depressed people view the world in a negative manner; they view
themselves in a debasing way; and they view their future as dismal. Cognitive therapy is a treatment designed to help
people learn to identify and monitor negative ways of thinking, then to alter this tendency and think in a more realistic
manner.
When depressed people learn to identify distorted automatic thinking and to replace them with more realistic ones,
depression can be reduced. Moreover, when people become adept at altering negative thoughts and beliefs, their
likelihood of experiencing episodes of depression in the future decreases.
15
To some this may sound overly simplistic. You might be thinking, "I've been depressed for years and you are trying to
tell me that that all I need to do is think positively and it will all go away?"
This is a common response to some people when they first hear about cognitive therapy. First, though the notion of
thoughts causing feelings is quite elementary, the actual information processing biases which occur in depression are
really quite complex. Volumes of research investigating biases in memory retrieval, attention and processing structures
that are activated in depressive states suggest that what happens cognitively in depression is far from simplistic. One of
the things that research has discovered is that just "thinking positively" is not going to decrease depression in a lasting
way. Though depressed people do not engage in a great deal of positive thinking, it is the negative thoughts, beliefs and
assumptions that perpetuate depressed mood. Negative thinking in depressed people largely occurs automatically and
sometimes without awareness. For cognitive therapy to be effective, depressed individuals need to learn how to identify
their negative automatic thoughts, processing biases as well as the beliefs they have about themselves and others.
Depressed individuals also need to learn to dispute their negative thoughts after they have been identified. Therefore, as
opposed to positive thinking, cognitive therapy helps people think non-negatively. For many this requires the learning of
new skills: monitoring ones stream of thoughts, identifying beliefs and attitudes and subjecting them to the laws of
reason. With enough practice, these skills become second nature, and the risk of severe depression decreases.
Therefore, cognitive therapy is more educational than other non-directive forms of therapy. Cognitive therapy is not a
"magic bullet." In order for one to benefit from it, effort must be placed on using the skills outside of therapy. Some find
the initial sessions of cognitive therapy difficult, because the skills do not result in complete elimination of symptoms. I
liken cognitive therapy to learning a foreign language. At first the tasks of self-monitoring, activity scheduling and
thought disputation feel awkward and the outcome doesn't seem to be worth the effort. Like learning a foreign language,
the more practice put into using cognitive therapy skills, the more effective they will become, the more automatic they
will become and the more lasting will relief be.
In many ways cognitive therapy may sound like school; much of the therapy entails didactic presentation, and
homework is assigned. However, it is more accurate to view cognitive therapy as an interactive workshop. A very good
self-help book on using cognitive therapy for depression is "Feeling Good" by David Burns, M.D. In my opinion, this
book is the best "self help" manual for cognitive therapy of depression. It can also serve as a good adjunct to actual
cognitive therapy. It is available in paperback and widely available at most bookstores.
16
THE STRUCTURAL MODEL OF COGNITION
Robert Westermeyer, Ph.D.
(Some of the information in this article is based on the work of Judith Beck, Ph.D., author of the wonderful text,
Cognitive Therapy: Basics and Beyond, on Guilford Publications)
Our information processing system is amazingly efficient. Memories of our experiences are stored and configured
efficiently into structures called schemas. Schemas serve as filters for ongoing experience, allowing us to come to
conclusions about events automatically. Each of us has a unique stockpile of memories, so the conclusions made about
events will vary from person to person, as will the emotions we experience.
Certain schemas cause behavioral and emotional problems. These schemas are formed early on in life as a function of
negative experiences. They are built upon by experiences that occur throughout our lives. We call these schemas
dysfunctional schemas, or dysfunctional core beliefs. For example, repeated experiences as a child of inconsistency,
harsh criticism, conditional statements of love, might form a core belief in which the person feels "flawed." Such a core
belief would make this person vulnerable to depression.
It is unusual for a person who has a core belief having to do with feeling flawed to believe he or she is "flawed" all the
time, because such people usually have memories which conflict with this belief. For example, the person might not feel
"flawed" when complimented by others, or when a task is completed perfectly. Given the fact that depression is a very
negative mood state, our information processing system configures this other information to make the activation of such
core beliefs as "I'm flawed" less likely. We develop what are referred to as conditional beliefs, or rules, which can be
verbalized in the form of "if-then" statements.
For example, if approval from others has been associated with feeling okay about yourself, you might develop a
conditional belief that reads, "If people voice approval, I might be okay," or "If people don't voice approval, or voice
disapproval, then I'm flawed." Let's say that perfect performance has been associated with positive thoughts about
yourself. It is likely that you will develop a conditional belief that reads something like, "If I do everything perfectly, I
might not be flawed," or "If I am less than totally perfect, then I'm flawed."
This framework of core beliefs and rules would be supported by certain PROTECTIVE BEHAVIORS, (because they
protect us from the activation of dysfunctional core beliefs). In the above mentioned configuration of beliefs,
compensatory behaviors might include "approval seeking," "inauthentic behavior," "perfectionism," "avoidance." These
techniques are protective, in that they prevent situations from leading to activation of the core belief, in this example,
"I'm flawed."
Based on this framework, a person will have unique distortions in their on-going automatic thoughts. For example, lack
of approval after a task might lead to the automatic thought, "I did a bad job." Small mistakes in performance might
lead to the automatic thought, "I'm an idiot."
It is important to understand that the above system of thinking and behaving strengthens the system. For
example, the conclusion that one is "an idiot" after less than perfect performance reinforces perfectionistic protective
behavior, strengthens the conditional belief, or rule, and adds yet another memory to the continuously growing core
belief, "I'm Flawed."
In cognitive therapy it is believed that people can change these "dysfunctional cognitive loops." METACOGNITION is
the ability to think about thinking. This uniquely human capacity enables us to interrupt such self-strengthening loops
and alter biased or distorted ways of thinking and behaving. It is believed that the more effort put into changing
automatic distorted thinking and protective dysfunctional behaviors, the more automatic healthy thinking will become.
17
Cognitive therapy focuses on change at all levels; automatic thoughts, behaviors, protective rules, core beliefs.
1. AUTOMATIC THOUGHTS. Each time a distorted automatic thought goes unchecked, it strengthens dysfunctional
core beliefs and conditional rules by adding yet another memory to the schema. Each time a dysfunctional automatic
thought is altered via thought record disputation, you have added a "conflicting memory" to the system and actually
changed the core structure. Keep in mind, automatic thoughts occur all day long, and if only one out of a hundred
distorted automatic thoughts is altered, it will have a minimal effect on the core belief. So, the more the better when it
comes to thought records!
2. CONDITIONAL BELIEFS (RULES). In cognitive therapy, an attempt is made to help you identify conditional rules
and find more flexible healthy alternatives, then test them out via cognitive disputation and actual behavioral
experiments.
3. PROTECTIVE BEHAVIORS. Exposing oneself to behaviors which counter dysfunctional protective ones is a
powerful part of cognitive therapy. This sometimes requires practice in group (as is often the case with assertiveness).
We recommend that individuals change protective behaviors gradually, so that it is not overwhelming. If change efforts
are too overwhelming, they are likely to be abandoned.
4. CORE BELIEFS. Core beliefs are, in essence, our realities. Therefore, they are not as readily alterable as automatic
thoughts (which are the products of core beliefs). Longer-term cognitive therapy will focus a great deal on core beliefs.
In cognitive therapy, the following techniques are used to help you identify and begin to change core beliefs:
THOUGHT MONITORING AND DISPUTING. Thought monitoring can be a good way to begin to understand core
belief themes (by virtue of their frequency): As stated, altering automatic thoughts adds conflicting memories to the
schema system which can alter core beliefs gradually in time.
PRESCRIPTION OF HEALTHIER, MORE FLEXIBLE CORE BELIEFS. In cognitive therapy, attempts are made to
help you move away from behaviors and thinking which support dysfunctional core beliefs and toward healthier more
balanced ones. Clients are encouraged to review evidence which supports healthier core beliefs frequently, and to also
review evidence which supports dysfunctional core beliefs, disputing exaggerated or distorted "support."
EXPERIMENTING HEALTHIER CORE BELIEFS. After a healthy substitute for a dysfunctional core belief is
prescribed, it is important to plan "experiments" for ourselves, in which we enter situations "as if" (a term used by Judith
Beck, Ph.D.) the prescribed belief were true. These experiments can lead to outcomes that support the new belief, thus
adding REAL conflicting memories to the system.
REPROCESSING OF OLD MEMORIES. Cognitive therapy is not only useful in helping you dispute distortions in your
every day life, but re-thinking old memories which have lead to dysfunctional core beliefs. We recommend that this
"core belief work" is done in therapy, as it can be a painful experience, especially when you are not particularly versed
in cognitive therapy techniques. Guidance from a professional is deemed appropriate.
Figure 1. Structural Model
The configuration of core beliefs, rules, protective behaviors leads to distorted automatic thoughts which strengthen the
existing style of thinking and behaving at all levels.
18
Figure 2. Example:
19
THE COGNITIVE MODEL OF DEPRESSION
Robert W. Westermeyer, Ph.D.
The experience of depression is amorphous, like a thick, dark fog. In cognitive therapy, depression is broken down into
its symptom categories so that the tangible aspects can be identified. As you will see, preventing certain depressive
symptoms from maintaining the state is what cognitive therapy is all about. Below are the four general symptom areas of
depression.
Depressive symptoms feed one another, and this is what prolongs the state. Consider the example of an applicant who is
turned down after a job interview and comes to the following conclusions: "I'm a loser, I'm unemployable" These selfstatements will certainly make her feel sad and guilty (emotional), which in turn will lead to a lethargic, listless physical
state (physical), to which she might elect to spend all day in bed (behavioral), leading to insomnia that night (physical).
During the wakeful hours of darkness and silence, she has other thoughts like "I can't do anything with my life"
(cognitive) and to conjure ugly memories of past failures (cognitive). She'll undoubtedly have decreased energy the next
day (physical) and find it hard to concentrate (cognitive). She may elect to cancel her lunch date with her friend
(behavioral) then think thoughts like "my whole life is falling apart," (cognitive). This, in turn, will add anxiety to her
experience (emotional) which will add restlessness to her fatigue, (physical), which may lead to the decision to cancel
another scheduled job interview the following day (behavioral) and so on…
Depression is a mood state with many causes: negative life events such as divorce or cumulative stressors on the job;
biological changes, as is the case with postpartum depression and bipolar illness; or by the presence of dysfunctional
beliefs such as "I'm unlovable". Though depression has various triggers, once it is activated the symptoms are akin
regardless of the cause. What is particularly insidious about depression is that when the symptoms are allowed to cycle
automatically, the state can maintain itself for weeks, even months.
Consider the downward spiral depicted in the figure below:
20
The figure emphasizes the fact that symptoms of depression are not just by-products, but actually serve to strengthen and
prolong the depressive state. This may seem like a very discouraging model, but it also offers the logical conclusion that
if depressive symptoms perpetuate depression, the reduction of these symptoms would weaken the state. And this is
exactly what research has shown. Though depression is a self-fueling state, the cognitive and behavioral symptoms that
worsen the state are tangible, and when modified, weaken it.
Many people in the throes of clinical depression don't think that their mood varies much, that it is always pretty much at
the same miserable level. Quite the contrary; even very depressed people experience changes in their mood throughout
the day. The periods of reduced depression are far from insignificant; they are periods when the depression is actually
weakening--albeit because of the strength of the depression, these periods don't result in any lasting improvement of
mood.
Furthermore, the behaviors and attitudes associated with relief tend to be those that counter the aforementioned
behavioral and cognitive symptoms of depression (i.e., withdrawal, reduction of pleasurable activities, inactivity,
hopelessness, helplessness and worthlessness). Recovery from depression occurs gradually as people increase these
sorts of activities and consistently modify negative thinking.
One simple way of viewing cognitive therapy of depression is that it focuses on disallowing behaviors and attitudes
associated with depressed mood and increasing the behaviors and attitudes associated with non-depressed mood. The
more prolonged periods of improved mood a person can achieve each day, the weaker the depression becomes.
21
To test the hypothesis that consistently reversing cognitive and behavioral symptoms will lead to recovery from
depression, it is recommended that individuals begin structuring their days with activities associated with non-depressed
mood, and monitoring their mood throughout the day. The activity monitoring/planning form offers opportunities to
rate the amount of pleasure associated with every hour of the day, as well as to gain insight as to the activities associated
with mood improvement and mood deterioration. It is also an opportunity to begin monitoring your automatic thoughts.
Complete an activity monitoring/planning form for each day (preferably the day before). Days should be structured as
though you were not depressed (e.g., normal wake up time and bedtime, no prolonged periods of withdrawal and sleep
in the daytime). Each day should also have the three following activities: Something potentially pleasurable; something
that will bring about a sense of accomplishment; something involving others.
It's common to feel a complete lack of interest in activities, and therefore feel hard-pressed to find pleasurable activities
to assign. It is therefore recommended that you complete a pleasurable activities inventory by listing things you used to
do before you were depressed that were associated with pleasure, and then assigning them to yourself. Also, because of
the low energy and concentration impairment of depression, it may not be possible to complete large tasks. Therefore, it
is reasonable to break down accomplishment tasks into smaller steps (for example, if bills need to be paid, an acceptable
step for the day might be going to the post office to buy stamps). Regarding social activities, it is the contact with people
that is important. Being physically around positive people is desirable, but a telephone call or an Internet dialog might
be a reasonable step if this is not possible on a given day.
In terms of the previously discussed symptoms of depression, negative thinking is the most powerful in terms of
perpetuating depression. When depressed people become proficient at identifying and countering cognitive distortions,
depression loses its strength. The aim of this program is for you to leave with this skill, which will not only result in the
reduction of your current depression, but also the ability to prevent future episodes.
22
THE COGNITIVE MODEL OF ANXIETY
Robert Westermeyer, Ph.D.
Anxiety is the most common of psychiatric complaints. Prolonged anxiety problems can disrupt work,
interpersonal relationships, and sleep; when anxiety reaches the heights of panic, it can be debilitating. Thankfully,
anxiety is quite treatable, and cognitive therapy for anxiety is one of the methods with considerable research support.
Like depression, it is useful to break anxiety down into its symptom categories such that the tangible aspects can
be identified. You will discover that like the cognitive behavioral approach to depression, moderating anxiety involves
disallowing the symptoms that perpetuate the state.
The emotional component of anxiety is fear. It is by anyone's definition a painful urgent emotion, like some
uninvited high voltage current running through you. Nervousness is used to describe low level anxious mood, and at the
opposite extreme, panic, a profound blast of anxious affect. The physical symptoms of anxiety are myriad; shortness of
breath, rapid heart rate, shakiness, dizziness, unsteadiness, numbness and tingling, lightheadedness, feelings of choking,
sweating. Most people reckon the physical symptoms to be the most distressing part of the anxiety experience. In terms
of cognitive symptoms, anxiety strongly influences attention such that one's focus becomes narrowly directed toward
the danger at hand. With some forms of anxiety (e.g. panic disorder, performance anxiety) attention becomes selffocused. With regard to memory retrieval, anxiety creates significant blocking of non-threat related information; you just
can't think of anything but what you're anxious about! When anxious, one's automatic thoughts and mental images tend
to be catastrophic; that is, there is an exaggeration of the dangerousness of the situation and a simultaneous
underestimate of one's control over that danger.
So, to summarize, when the anxiety experience is activated, there is an unsettling urgent emotion present,
intense physical involvement the body is alerted in a way that is impossible to ignore. Attention becomes narrowly
focused on whatever the source of the anxiety is to the extent that other information becomes inaccessible. Plus, the
disasterousness of the situation is amplified and control resources are minimized in one's mind. This quite rapid
activation of symptoms has one behavioral purpose, Flight. And it is without a doubt the most important mechanism, in
terms of survival, that we have in the circuitry of our brains. If anxiety didn't happen in the face of danger, we'd all
perish for sure. Anxiety alerts us to danger and makes us more likely to escape from it. However, some people
experience an inappropriate level of anxiety given the dangerousness of the situation and/or have enduring anxiety
despite a relatively safe environment. Anxiety problems can be described as false alarms that are too frequent, too
profound, and or too prolonged.
Anxiety problems are self-perpetuating, mostly by virtue of cognitive distortions and the overuse of
flight/avoidance strategies. Consider an example. Joe quit his job due to severe anxiety. He's been out of work for a
month. A friend orchestrated a job interview for Joe tomorrow, and the night before, he is catastrophizing and therefore
experiencing a considerable amount of anxious mood and physical symptoms. The more anxious Joe gets, the more
catastrophic he thinks, until he can't stand it any more and elects to cancel the interview. The canceling of the interview
brings about an immediate reduction of anxiety, and therefore, the next time Joe is offered an interview, he will not only
be likely to catastrophize and experience considerable anxiety, but he will also be strongly compelled to cancel the
interview. With several such scenarios, Joe becomes stuck in an anxiety/avoidance cycle that is very difficult to get out
of.
23
Treatments for anxiety focus on each of the four symptom groups:
Emotional: Medicines target the emotional symptoms of anxiety directly, for example, benzodiazepines influence the
neurotransmitters responsible for anxious mood (as well as the physical symptoms), as do some of the Serotonin
antidepressants. A sound pharmacological regime is often a necessary part of anxious individuals' treatment. However,
MDS are always mindful not to have their patients use sedating medications as the sole means of dealing with anxiety,
as they may come to depend exclusively on the medication, to the point in which medications are overused, or as-needed
anxiolytic medicating becomes an avoidant strategy in and of itself.
Physical: It is literally impossible to be anxious and relaxed at the same time. Therefore, skills for promoting relaxation
are very powerful in reducing anxiety. Progressive Muscle Relaxation is a method designed to teach you how to
recognize involuntary muscle tension and relax muscle groups. The diaphragmatic breathing technique is an exercise
that reduces the rate and increases the depth of breathing to promote relaxation. With considerable practice, anxious
individuals can learn to slow down their breathing during bouts of anxiety. Visualization techniques are aimed at helping
people bring about a relaxed physical state by conjuring up vivid and soothing experiences and fantasies.
Cognitive: Cognitive skills for managing anxiety involve distraction and decatastrophizing. Distraction is a very
powerful means of reducing intense anxiety and panic. When one is consumed with a high level of anxiety, it is very
hard to recognize and challenge distorted thoughts. However, if panic-stricken people can "get out of their heads" for a
few minutes by focusing intensely and exclusively on some outside stimulus (while at the same time using the
diaphragmatic breathing method) anxiety will diminish, often to a level where individuals can reason with themselves.
Decatastrophizing is a disputation technique aimed at balancing anxious automatic thoughts. There are two
methods of decatastrophizing:
COGNITIVE EXPOSURE. This method, which involves the consideration of worst case scenarios, is useful for
ruminative situations in which there is a chance of a moderately negative outcome. It is not advocated for situations in
which there is a remote chance of something extremely catastrophic, such as death, terminal illness, prison time, living
on the street, as this technique will only lead to increased rumination and catastrophizing. Some appropriate events for
cognitive exposure would be, returning to work, being assertive with your boss, dropping a class, a job interview.
Cognitive exposure involves, first, thinking in a very vivid way about the worst potential outcome, then walking through
the steps as to what you'd really do about it if it actually happened. Though this technique might sound like ordinary
worrying, it is quite different. Worrying or ruminating is a self-protective strategy we engage in to prevent worst case
scenarios. With cognitive exposure, you are actually placing yourself in the situation. In your mind, there is no way you
can prevent it, because it has already happened. Anxiety reduction comes from mentally walking through the steps as to
what you would realistically do and discovering that, though undesirable, the outcome wouldn't kill you.
24
For example, consider a young man returning to a stressful job, the worst case scenario being, "having to quit".
Imagining this actually occurring puts the fellow in the position such that he must do something. The following
responses might come into his mind; "I'd cry…"I'd call friends for support"…"I'd probably receive support"…"In
several days I'll start looking for another job (reminded of his ability to always find work and good interview
skills)"…"I'd check out work in part of town closer to home"…"I'd eventually get job, possibly a less stressful job."
This exercise almost invariably leads to the realization of many, many safety nets and methods of coping, such
that worst case scenario, though negative and certainly not desirable, would not be devastating. In some instances, such
as the above, worst case scenarios can even yield positive outcomes.
The next step is to conjure up vividly the best case scenario. It is important to focus on worst case first, as best
case will seems absurd until you've convinced yourself you can handle the worst case. Using the above example, the best
case scenario might be returning to work and finding things to be considerably less stressful due to changes initiated by
his boss and better stress management skills.
After imaging both worst and best potential outcomes, the logical conclusion is that all outcomes in-between
could be managed; however, as a third step, entertaining one or two realistic case scenarios places you in a balanced
state of mind. Again, it isn't until the most terrible outcome is "exorcised" that the more likely realistic outcomes can be
entertained in a believable way. Using the example, a realistic outcome might be returning to find things a bit less
stressful due to increased ability to manage stress and approaching the first week on the job a trial period during which
other job opportunities will be investigated so that if things end up being overwhelming, a smooth transition can be
made.
REDUCING THE GAP. Above, catastrophic thinking was described as an exaggeration of danger and an
underestimate of one's control over that danger.
When the conceptualization of control is in line with that of danger, that is, when there is no space between the
two continua, then anxiety is absent. For example, imagine you're downtown, and there is an intoxicated lecher barreling
down the sidewalk toward you with a nasty scowl on his face and a crowbar in his hand. Now, most of us would deem
that a pretty dangerous event. However, it's the middle of the day, and there's three muscle bound vigilantes walking
right in front of you, plus a row of open doors parallel to the sidewalk leading into the police station plus you are a triple
black belt in Tai Quan Do, then the control one has is pretty much in line with the dangerousness of the event. Now, if
we change the time of day to three a.m. , put closed signs on all the police station doors, a cast on your leg and a pair of
crutches. Now we have a considerably more dangerous situation with much less control over it, and consequently some
pretty intense anxiety.
The above conceptualization suggests that the level of anxiety is less a function of specific dangers or controls,
and more the "distance" between these two conceptualizations that will determine the amount of anxiety. The greater the
gap between our conceptualization of danger and our conceptualization of control, the greater the anxiety. Moving away
25
from the example of menacing thugs and crutches, we could imagine the danger of a job interview, conceptualized as
hostile interviewers with impossible questions, and our control over the interview as next to nil, in that there will be an
inability to respond, anxiety, tearfulness, possible fainting. Here, though the actual situation would seem by most to be
less dangerous, the gap could result in a level of anxiety commensurate with the example involving thugs and crutches.
Reducing the gap involves, first, translating your anxious mindset into beliefs about danger and beliefs about
control, then performing a test of evidence on each of those beliefs to determine whether they are biased. The
decatastrophizing form that follows this article offers an opportunity to begin challenging catastrophic thoughts.
Behavioral symptoms: Countering avoidance is believed to be the most powerful means of reducing anxiety problems.
Avoidance reduces anxiety in the short term, but it actually makes for more anxiety in the long term, as avoidance
breeds more avoidance and it becomes increasingly more anxiety provoking to counter avoidance. Using the example of
the young fellow returning to work, if he catastrophizes returning to the extent that his anxiety is extreme, he may
choose to postpone it. This will decrease his anxiety and make it even harder to return the next day, because not only
will he have increased anxiety just considering it, but he will have a strong drive to postpone again, given that the
previous postponement resulted in a decrease in anxiety. Exposure involves placing oneself in the avoided situation,
despite the anxiety, and staying there until the anxiety ebbs completely. With most forms of anxiety, a hierarchy of
exposure is established; i.e. the person gradually exposes himself to what has been avoided, starting with a level that
evokes a minimum of anxiety, and increasing the level of exposure as each level is successfully extinguished, while
simultaneously utilizing relaxation exercises and decatastrophizing techniques.
This method of exposing anxious individuals gradually is called systematic desensitization and was originally
used to help people with phobias. For example, a snake phobic would be exposed first to photographs of snakes, and
asked to look at them while using relaxation and decatastrophizing skills until the photos no longer cause anxiety. Then
the person would be exposed to a realistic rubber snake, here touching it, holding it, while using relaxation and
decatastrophizing skills until the anxiety diminishes completely. The next exposure step might involve a live snake in a
locked aquarium, and several more steps all the way up to holding a live harmless snake. Systematic desensitization as
applied to the young fellow returning to work might have as an initial step driving around the parking lot of his job on a
Sunday, followed by talking to a colleague on the phone, and then visiting work prior to returning, starting part time,
eventually back to full time employment.
One of the reasons anxiety is so treatable is that there are so many potentially effective ways to intervene.
Though everyone is different as to which methods are most effective, it is recommended that all the aforementioned
skills are practiced. Unlike skills for managing depression, some of the cognitive behavioral techniques designed to
help you reduce anxiety necessarily cause an increase in anxiety prior to a lasting reduction. It is important to continue
with the techniques despite the temporary increase, as it is a necessary part of the recovery from anxiety. Using an
exercise analogy, when someone who is out of shape begins to work out, it is typically excruciating, and there is often
strong motivation to abandon the regime. If he or she keeps with it, the workouts become easier, enjoyable even, as he or
she becomes more toned and attractive.
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Anger Management
Robert W. Westermeyer, Ph.D.
Anger, in and of itself, is not dysfunctional. Anger is an emotion, which, like anxiety, affects many systems (emotional,
cognitive and physiological). It is typically activated when a person believes he or she has been deliberately provoked.
In terms of survival, anger can be looked at as a necessary driving force when "fight" as opposed to "flight" is required.
Cognitively, research has shown that when angry, people show changes in their thinking (Novaco, 1979). Typically
people become "single minded," focusing exclusively on what they believe is provoking them. Most people's anger is
isolated to situations in which it is justified, when they have been taken advantage of, lied to, cheated, abused and so
forth.
Some people, however, have "anger control problems" They just seem to be always angry. Even when nothing really
appears to be provoking them, these people are feeling incited, taken advantage of, belittled, or abused in some way.
Sometimes their perceptions are accurate, other times they are distorting their experience massively.
Some people find it very hard to express their anger. They may have internal rules and standards that mandate that anger
"must not be openly expressed". This sort of self-discipline can lead to problems, because anger that is not expressed
tends to "stockpile". Unexpressed anger keeps a person aroused physiologically which can lead to health problems like
high blood pressure and even heart disease. Also, unexpressed anger can cause feelings of helplessness, which can, in
turn precipitate depressed mood. Therefore, for people with unexpressed anger, it is important for them to identify their
anger, identify what beliefs are keeping them from expressing it, and to find appropriate channels for its expression.
A far more common problem is that of people exaggerating the provocation in situations, particularly interpersonal ones,
such that they feel intense and prolonged anger unnecessarily. This unnecessary anger often leads to an exaggerated
expression of anger-- often toward others.
People can do many things to reduce anger, relax, meditate, distract themselves (e.g. the old advice of counting to ten) or
talk about it. All of these techniques can be helpful for some people. Some believe that hitting a pillow, a punching bag
or the like will "vent" the anger. I believe that though doing such things feels good, it doesn't do anything to reduce what
it is that is bothering you. You may become exhausted, and therefore relax a bit, but your anger can be easily triggered
soon after hitting a pillow by an innocent passerby. Furthermore, venting anger can actually increase the intensity of the
state.
As with depression and anxiety, cognitive techniques can be very helpful in reducing anger and lessening the intensity of
future outbursts. Many researchers have discovered that anger control problems tend to be associated with a number of
"thinking errors" (Lochman, 1984; Dodge and Frame, 1982; Foreman, 1980; Little and Kendall, 1979; Lochman, White,
Wayland, 1991).
1. Cognitive Deficits: People with anger control problems have an insufficient number of adaptive responses to
provoking events. Research has shown that angry people, when asked how they would solve provocative situations, have
fewer ideas than people without anger problems. There few ideas, not surprisingly, tend to be hostile.
2. Frequent False Positives: People with anger control problems often misconstrue events such that they feel provoked
even when they are not. It has been found that people with anger control problems tend to be vigilant for presence of
people deliberately hassling them. Therefore, due to only seeing part of the picture, they tend to misconstrue innocuous
frequently.
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3. Rigid Beliefs: People with anger control problems often possess steadfast beliefs as to the legitimacy of hostile
retaliation. Some examples include, "Hostility is okay if someone does something to provoke it." or "The best way to get
your needs met is to demand it." or "People are, for the most part, stupid and need to be dealt with forcefully." It is not
difficult to imagine how adhering to such beliefs might lead to some volatile encounters.
4. Difficulty Anticipating Outcomes Before Action: People without anger problems are able to control how they
respond to anger and actually keep it from getting out of control by predicting what "could" happen if they "lost it."
People with anger problems tend to respond quickly without such forethought.
Dr. Eva Feinder is an expert in the area of anger control training (1986, 1991). She has developed an anger control
program that targets aggressive adolescents. Her program has helped kids gain control of their anger by learning how to
step back in an angry situation and evaluate accurately. Anger has a swift onset. There is no more effective way to
control angry escalation than to nip it in the bud before It gets out of control. This requires learning how to alert yourself
to the subtle signs of increasing anger.
With regard to interpersonal anger, Dr. Fiendler recommends that people try, in the heat of an angry moment, to see if
they can understand where the alleged perpetrator is coming from. Empathy is very difficult when angry, but it can make
all the difference in the world. Isn't it frequently the case that when we get intensely angry at someone, the next day we
feel guilty to some degree? We may say to ourselves something like, "You know, they did have a point. I sort of overreacted." Taking the other person's point of view can be excruciating when in the throes of anger, but with practice it can
become second nature.
Dr. Fiendler also recommends that when angry you try to listen carefully to what is being said to you. Anger creates a
hostility filter, and often all you can hear is negatively toned.
The following are some questions you can ask yourself when you notice you are getting angry. These questions serve the
same purpose as those used to combat depressive and anxious thinking--to make distortions disappear.
WHERE IS THE EVIDENCE?
Is there sufficient evidence to back up the interpretation you have made of the event that is angering you?
e.g. Someone is late for dinner and you say to yourself, "That selfish bastard doesn't care that I have made dinner."
WHERE IS THE EVIDENCE? Is this person really a selfish bastard? Are there qualities which do not support this
interpretation?
IS THERE ANOTHER WAY OF LOOKING AT THIS EVENT?
Try to entertain one or two other explanations for what you've interpreted as "deliberate provocation." After all, there are
two sides to every coin. Often this is enough to at least decrease anger to the level of mild frustration.
e.g. (same scenario) Could there be a reasonable explanation for lateness. Is there traffic? Could something have come
up, which will become known when he arrives? Have I sufficiently told him that being on time is very important to me
and to please call if late?
SO WHAT?
Rarely are things as catastrophic in reality as they seem in the heat of the moment. so the driver in the red Porsche cut
you off. So what! Will it amount to anything three hours from now? Has your dignity as a driver really been damaged?
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e.g. So what if he's late. Let's say he's twenty minutes late. Is it worth ruining the whole evening by assaulting him right
when he comes in. Is it likely that it will be forgotten about after ten minutes of chatting?
WHAT WILL THE OUTCOME BE?
Thinking of potential outcomes of our actions is not easy, much less when you are in a state of anger. Anger is by nature
"single minded." Extreme anger almost always has negative outcomes when it is taken out on another person. See if you
can train yourself to step into the future in the heat of the moment.
e.g. Could getting all aroused with anger end up ruining the evening. What if you do verbally assault him for being late.
What could happen? Could it put a damper on the evening? How would you respond if you had a legitimate reason for
being late and were nonetheless attacked. Would you want to turn around and drive home?
WHERE IS THE OTHER PERSON COMING FROM?
Anger creates cognitive myopia. Symptomatic of anger is a narrowing of focus on what we perceive as injustice. So it's
harder to empathize with others when we are angry. Force yourself to empathize EARLY ON, before anger is out of
control. Imagine yourself in the other person's shoes. "What would I be thinking She was coming across like I am right
now?" Even just momentarily considering the validity of the other person's feelings can be enough to ebb anger to the
extent that it is manageable.
Anger is one of the most difficult emotions to control, because it has a sudden onset and escalates quickly. As Dr.
Fiendler recommends, the key to effectively controlling anger is to slow things down. Once you have learned to
recognize early arousal signs and how to step back and evaluate the situation thoroughly, anger will lose a great deal of
its power.
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PIN-POINTING NASTY COGNITIONS
Robert W. Westermeyer, Ph.D.
Albert Ellis was a pioneer in the area of cognitive therapy (e.g. Ellis, 1961; Ellis and Grieger, 1977). Back in the 60s he
developed what he called the A-B-C model. This model, according to Ellis, describes the sequence of events that
ultimately lead to our experienced feelings. He recommends that people break down their experience into these three
areas in order to discover if distortions or "irrational beliefs" are present. "A" refers to Activating Event. Activating
events are the experiences we encounter. These events are described in objective terms and all views or opinions about
the event are not considered. "B" refers to Belief. Here what the event means to you is listed. In other words, what do
you believe to be true about the event "A?" The difference between an activating event and the associated belief is that
"A" will be the same for all, yet the way the event is construed will vary from person to person. "C" refers to Consequent
Emotion, the resulting feelings experienced as a result of our interpretation of the event. Ellis contends that people differ
with regard to their feelings associated with events solely due to the fact that they have different interpretations.
For example, imagine two people are intimidated in a bar and only one resorts to becoming angry and punching the
antagonist. If our emotions are a product of experience only, then why did only one get angry enough to punch the guy?
If emotions were caused solely by events then both would have resorted to violence. Ellis would contend that the two
people appraised the provocation in different ways. Consider four possible emotional outcomes of the same event:
What this illustration suggests is that our emotions are largely dependent on how we evaluate ourselves, events that
befall us, our actions and the actions of others. Each of us establish in the course of our lives a basic understanding of
ourselves and the world around us.
Therefore people are going to differ with regard to the styles of thinking they engage in on a regular basis. Some people
make very dismal and hopeless interpretations of everything. Consequently, these people tend to be down more often.
Others seem to see provocation in just about everything, and they are therefore angry a good deal of the time. Some
people, on the other hand, seem to be able to assess most situations in a manner that rarely makes them experience the
extremes of negative emotions. They just seem to be "balanced" emotionally most of the time. The last example in the
ABC illustration represents a much more balanced (and probably more accurate) interpretation of the bar patron's
insulting behavior.
In cognitive therapy, people learn how to pay attention to automatic thoughts and recognize those which are distorted.
There are a number of techniques which can be easily implemented when distorted thoughts are identified so that more
balanced, realistic interpretations can be discovered.
Cognitive therapy techniques are simple in theory but require constant practice. Remember, by paying attention to your
thoughts and altering them, you are going up against a powerful process; stream of consciousness thinking. We are
constantly thinking, and most of the time we don't put a great deal of effort into addressing the logic of our thoughts, we
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just trust them to be sound and reliable. In order for cognitive techniques to work for you, you have to practice them
every day. Every time you identify a distorted thought and modify it, you have strengthened a new way of thinking,
which can eventually become automatic. Each time you miss out, or ignore a distorted thought, you strengthen old ways.
This does not mean that you will be forced to scrutinize every thought which enters your mind for the rest of your life-this would make anyone crazy! The key is to implement most where the distortions lie. Few think erroneously all the
time. The more effort you put into practicing cognitive techniques in high risk situations, the less risky they will become.
The first step in tackling negative thoughts is to learn how to "tease" them out of your every day experience. Aaron
Beck, who developed cognitive therapy of depression(Beck et. al.,1979), recommends monitoring your thoughts
throughout the day. This way you gain "proof" of the inordinate amount of negative thinking which occurs when
depression is present. Your self monitoring form should look something like the one below.
Below are explanations as to how to fill out the first three columns accurately.
EVENT: What is happening right now. The event should be listed in very objective terms, like "playing cards with my
sister." as opposed to "Sister acting like a total bitch while playing cards." Any interpretation of the event will be listed
under Automatic thoughts.
EMOTIONS: How do you feel? Some people confuse feelings for thoughts. They may say, I feel ripped off! In actuality,
"ripped off" is not a feeling, it is a belief. How do you feel about being ripped off? Angry? Sad? Then rate your emotion
on a scale of 0-100% (0=no negative emotion, 100=the most intense this negative emotion can be experienced). It is
useful to create your own mood ruler by thinking about events in your past which have been associated with different
percentages of the negative mood and compare current mood states to these events for accurate gauging. For example,
0% depression might be likened to a honeymoon, 25% to normal hassles of the day, like waiting in line, 50% to an
extreme argument with a close friend, 75% with losing, 100% with the dissolution of a marriage.
AUTOMATIC THOUGHTS: What did you say to yourself in response to the event? What went through your mind?
Your automatic thoughts are the beliefs attached and meaning assigned to events. For example the automatic thoughts
associated with the event, "calling old girlfriend and being hung up on." might be, "I'm a loser...I completely ruined any
potential for a relationship." It is important to pinpoint the automatic thought which is causing you to feel badly. This is
often difficult, as there are always many thoughts occuring. Do a quality check on the automatic thought you have
identified. If "I hope the grocery isn't crowded" is the automatic thought you have associated with 75% depression, you
have not identified the true culprit cognition. Because, in and of itself, this automatic thought would not lead to this
severity of depression. Knowing the COGNITIVE THEMES OF NEGATIVE EMOTIONS can be helpful in identifying
the cognitions most related to the negative mood state:
1. DEPRESSION
A. COMMON THEMES: HOPELESSNESS, WORTHLESSNESS, HELPLESSNESS
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B. COMMON AUTOMATIC THOUGHTS: "I'M WORTHLESS", IT'S HOPELESS", "I CAN'T DO ANYTHING",
"I'M UNLOVABLE", "NO ONE LOVES ME", "NOTHING GOOD EVER HAPPENS TO ME", I'LL NEVER
AMOUNT TO ANYTHING", "MY FUTURE HOLDS NO PROMISE", "THERE IS NOTHING I CAN DO TO
CHANGE THINGS".
2. ANXIETY
A. COMMON THEMES: DANGER, VULNERABILITY
B.COMMON AUTOMATIC THOUGHTS: "IT WILL BE TERRIBLE", "I WILL CERTAINLY FAIL", "I WILL
NOT BE ABLE TO COPE", "PEOPLE WILL THINK I'M AN IDIOT", "NO ONE WILL LIKE ME", "I'LL NEVER
RECOVER".
3. ANGER
A.COMMON THEMES: BEING TREATED UNFAIRLY, DELIBERATE PROVOCATION, UNREASONABLE
OBSTACLES
B.COMMON AUTOMATIC THOUGHTS: "SHE IS DELIBERATELY TRYING TO ANGER ME", "THIS IS
NOT FAIR", "I SHOULD NOT HAVE TO TOLERATE THIS", "THERE IS NO REASON FOR HIS BEHAVIOR",
"SHE SHOULD KNOW BETTER", "THE ONLY REASON FOR HIM DOING THAT IS STUPIDITY".
So when you have identified an emotion, refer to the above description of cognitive themes. Ask yourself, "If I'm this
anxious, I must be feelign vulnerable to something? How would I word that?" or "If I'm this depressed, I must be feeling
some degree of hopelessness, helplessness and/or worthlessness. How would I word that?" This technique will make
your thought records efficient.
Here are some examples of self-monitoring lists which were filled out accurately:
The best time to monitor automatic thoughts is when you are feeling badly. The more monitoring the better, as this is the
data for scientific scrutiny, which comes next.
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DAZZLING YOURSELF WITH REASON
After monitoring your experience and breaking it down into these specific components, it is time to examine the
cognition--it must be determined whether the thoughts listed could benefit from some re-constructive surgery.
The forth column is labeled, "Balanced Comebacks." It is in this space that you subject your beliefs to the rules of
science. Scientists are particularly interested in experimental control and evidence. They are always conducting
experiments to determine whether their hypotheses are supported. Therefore, in cognitive therapy, your automatic
thoughts and beliefs are hypotheses to be tested. One way to modify biased thoughts is to know how thoughts become
distorted.
Below are the six common distortions:
1. THE MENTAL FILTER: You take the negative details and magnify them while filtering out all positive
aspects of a situation.
2. DICHOTOMOUS THINKING: There is no middle ground. Things are either/or, black /white, good o/bad.
You're beautiful or hideous, perfect or a complete failure.
3. MIND READING: You can suddenly read minds. Without their saying so, you know exactly what people are
thinking, and especially with regard to you.
4. CATASTROPHIC EXAGGERATION: The worst case scenario is going to occur, and it will be intolerable.
5. BLAMING: You hold other people solely responsible for your anguish.
6. CONTROL BELIEFS:
A. I AM CONTROLLED: You feel completely at the mercy of external forces. You are helpless.
B. I MUST CONTROL: You feel that any ease on the reins control in your life will result in a fall so disastrous
you will never regain control.
Beck and his colleagues recommend several questions, which you can ask yourself when you suspect distorted thinking.
To determine whether your belief is completely accurate ask yourself, "What evidence I have to support the belief?"
and "What evidence you have which refutes it?" These questions are useful in identifying thoughts which are biased
in that they do not consider all available information. Beliefs like, "I've made a complete fool of myself" and "no one
loves me" are almost always distorted to some degree. You can divide a piece of paper and put the data which supports
the automatic thought on the left side, and the data which refutes it on the right side. If you have any data whatsoever on
the right side (usually there will be at least a little bit) then the automatic thought is necessarily biased, or missing data.
Consider the third example from the above self-monitoring: Where is the evidence that you are worthless? Worthless is a
pretty strong word. Perhaps you believe that the break up of a relationship which you valued more than any other is
evidence enough. Well than approach it from another angle: Where is the evidence that you are not worthless? Do you
have any relationships which are not tainted? If yes, does this relationship then make the general belief that I am
worthless inaccurate? Do completely worthless people morn lost relationships? Certainly not. The fact that you are
concerned about what happened is a sign of worth. Did you put any effort into the relationship what so ever? Yes? Does
that make you worthless? Probably not. More likely it makes you someone who either needs to pursue relationships with
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people who are accepting of this aspect of you or use the information and work toward modifying this quality. Either
way it is a sign of growth, not worthlessness!
So, after such empirical rigor, it is hard to resist the second investigative question to ask yourself. "Is there another
way of wording the automatic thought?" If the above question resulted in the identification of a distortion, then what
would be a more realistic way of thinking? What modifications to the belief would make it more balanced? In the above
example, it is apparent that the automatic thoughts were a bit skewed, to say the least. A much more realistic
interpretation would be something like, "The break up with Greg is no doubt a bummer. I miss him terribly. However,
we just didn't click. I thought we did, but I guess there were certain qualities that he didn't like. I'm not willing to give up
who I am, and I really think I put an effort into trying to make it work. I learned from this relationship and hopefully it
will benefit me in my future relationships."
Other questions which can be helpful in disputing biased cognitions are:
* What would my spouse, best friend, sibling (or anyone whom you admire greatly) say to themselves in this
situation?
Sometimes distancing oneself from the situation at hand is enough to help see it in perspective. Imagining that our
beliefs are being experienced by people we know to think realistically is often helpful in bringing a distortion into focus.
Almost everyone knows at least someone who seems to be able to view things in a way which doesn't make them feel
bad. How would they handle what you are grappling with?
* What would I say to my spouse, best friend, sibling if they were thinking the same thing I am?
Another distancing technique which many find helpful is to imagine someone you care deeply about voicing the same
belief. Almost everyone is better at picking up on an exaggeration of distortion in others than ourselves. Furthermore,
we all are better therapists of others than of ourselves!
* How could I look at this situation so I would feel less depressed. Is this view as reasonable as my first choice?
Brainstorming is a proven effective method for unlocking good ideas. Essentially, you must try to allow all ideas to
come to mind uninhibited. When disputing a potentially distorted thought, brainstorm all potential alternatives. You
might come across one or two which are much more appropriate, and make you feel better to boot.
It is important to capitalize on every opportunity to counter depressive thoughts. In time, if you keep at it, you will
notice that reasonable examination of automatic thoughts will become second nature. This skill will enable you to
manage negative mood throughout the day and make you much more robust to the emergence of clinical levels of
negative mood.
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