rachelmanija (![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
rachelmanija) wrote2012-07-24 11:15 am
rachelmanija) wrote2012-07-24 11:15 am
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Cognitive Therapy and the Emotional Disorders, by Aaron T. Beck, MD
Classic work on cognitive therapy by one of its founders. Parts are technical, but overall it’s straightforward, easy to read, and a good introduction.
The basic idea of cognitive therapy (CT) is that a lot of anxiety is caused by thoughts. Typically, these are negative, irrational, automatic thoughts which go on at a low level of consciousness – not unconsciousness, but a sort of background chatter which you may not be aware of, but can easily call into awareness if you pay attention. Stuff like, “She hates me,” “I’m a loser,” “They won’t hire me,” etc.
These thoughts are what cause or precipitate anxiety, depression, and panic attacks; if you become aware of the thoughts, then you can challenge them and teach yourself to think them less. You will then be less depressed, anxious, and panicky. (Mindfulness-based CT suggests that all CT works not by literally changing your thoughts, but by changing your relationship to your thoughts. I think both are a factor, but I’m with the mindfulness camp that the relationship aspect is more significant.)
That’s the basic theory. I’ll highlight details I thought were especially interesting.
- Trust your client. If you ask them what they were thinking before the anxiety attack, you may have to make them dig a little, but eventually they’ll come up with something. Trust what they give you. They know what they thought. Also ask for visual images and fantasies.
- Look for personal meanings. The public meaning of “hospital” is “place where people go to be cured.” Your hospital-phobic client may have the personal meaning of hospital be “place where people are anesthetized, cut up, and die.”
- This relates to root-cause beliefs. The negative thought might be “They don’t like me.” Asking why it’s important to be liked may eventually elicit something like, “I must be liked by everyone always, or I’m worthless,” or “I should be so wonderful that everyone loves me.” (Shoulds are generally harmful and unrealistic. Listen for them.)
- Depressed/anxious people often think everything relates to them: if someone glances their way, it proves the person hates, scorns, or is laughing at them. They will gain in self-esteem once they consciously consider that they are not the center of the universe. (The single most important insight I got from doing CT, by the way. It sounds obvious but in real life, it’s very easy to forget.) This can be subtle: you hear about someone having a heart attack and think, “That could happen to me.” Sure, it could. But in reality, that’s someone else’s heart, not yours.
- Explain how CT works in advance. You are collaborating with your client; don’t rigidly stick to your own agenda. Check in periodically to make sure you’re on the same page; ask them if they disagree, and make sure they believe that disagreement is fine. Ask them to state areas of agreement and disagreement. Also, don’t set yourself up as Superman who’s going to swoop in and solve all your client’s problems. They need to know that this is a partnership and they have to put in some serious work.
- Cognitive distortions are one thing, but you can’t reason people out of actual delusions. However, you can sometimes get clients to stop acting on delusions by discussing the consequences of their behavior with them. (ie, they may still think their neighbor is the Devil, but be convinced that it would not be in their best interest to break his windows.)
- When clients come in with multiple problems, try to find a common theme, then tackle the theme. Similarly, try to see if there’s a single problem which is causing all the others, then tackle that. (ie, multiple problems caused by root “fear of social interaction.”)
- You don’t need to solve ALL the problems. Once the major crises are resolved and the client has a handle on CT techniques and can use them on their own, they’re good to go. Other stuff will come up, but the important thing is that now they’re equipped to handle it.
- Experimentation: teach clients to figure out what their negative thoughts are (if it’s not obvious) by recording thoughts before and during moments of anxiety/depression. Journaling is good for this. Eventually, patterns will emerge. Once the thoughts have been moved to conscious awareness, you can discuss whether or not they’re valid. Simply learning to observe one’s own thoughts often creates distance, which lessens the emotional impact. (This is the core of the mindfulness-based approach.)
- If they don’t see how thoughts are unrealistic in conversation or if it’s not sinking in emotionally, they can test their thought-hypotheses via real-world experimentation. (Is it really true that going to the party will be the worst experience ever?)
- Discuss the worst that can happen. Some negative thoughts do involve real possibilities. But in depressed people, the worst outcome is assumed to definitely happen, and goes way beyond bad stuff that could realistically happen. You want people to think, “My speech might be awesome, or average. But if it’s terrible, the worst that will happen is I’ll be embarrassed for a few days and that will suck, but it’s unlikely to affect my job and my husband will be very sympathetic,” rather than, “My speech will definitely be terrible, and I’ll get fired, and everyone will scorn me, and I will be humiliated forever.”
- Cognitive-behavioral interventions for depression: schedule activities. Have client rate activities for feelings of pleasure and mastery (accomplishment.) Consider alternative explanations and alternative actions. Cognitive rehearsal (imagine yourself doing stuff successfully.) Homework: experiments, log of automatic thoughts.
Cognitive Therapy and the Emotional Disorders
The basic idea of cognitive therapy (CT) is that a lot of anxiety is caused by thoughts. Typically, these are negative, irrational, automatic thoughts which go on at a low level of consciousness – not unconsciousness, but a sort of background chatter which you may not be aware of, but can easily call into awareness if you pay attention. Stuff like, “She hates me,” “I’m a loser,” “They won’t hire me,” etc.
These thoughts are what cause or precipitate anxiety, depression, and panic attacks; if you become aware of the thoughts, then you can challenge them and teach yourself to think them less. You will then be less depressed, anxious, and panicky. (Mindfulness-based CT suggests that all CT works not by literally changing your thoughts, but by changing your relationship to your thoughts. I think both are a factor, but I’m with the mindfulness camp that the relationship aspect is more significant.)
That’s the basic theory. I’ll highlight details I thought were especially interesting.
- Trust your client. If you ask them what they were thinking before the anxiety attack, you may have to make them dig a little, but eventually they’ll come up with something. Trust what they give you. They know what they thought. Also ask for visual images and fantasies.
- Look for personal meanings. The public meaning of “hospital” is “place where people go to be cured.” Your hospital-phobic client may have the personal meaning of hospital be “place where people are anesthetized, cut up, and die.”
- This relates to root-cause beliefs. The negative thought might be “They don’t like me.” Asking why it’s important to be liked may eventually elicit something like, “I must be liked by everyone always, or I’m worthless,” or “I should be so wonderful that everyone loves me.” (Shoulds are generally harmful and unrealistic. Listen for them.)
- Depressed/anxious people often think everything relates to them: if someone glances their way, it proves the person hates, scorns, or is laughing at them. They will gain in self-esteem once they consciously consider that they are not the center of the universe. (The single most important insight I got from doing CT, by the way. It sounds obvious but in real life, it’s very easy to forget.) This can be subtle: you hear about someone having a heart attack and think, “That could happen to me.” Sure, it could. But in reality, that’s someone else’s heart, not yours.
- Explain how CT works in advance. You are collaborating with your client; don’t rigidly stick to your own agenda. Check in periodically to make sure you’re on the same page; ask them if they disagree, and make sure they believe that disagreement is fine. Ask them to state areas of agreement and disagreement. Also, don’t set yourself up as Superman who’s going to swoop in and solve all your client’s problems. They need to know that this is a partnership and they have to put in some serious work.
- Cognitive distortions are one thing, but you can’t reason people out of actual delusions. However, you can sometimes get clients to stop acting on delusions by discussing the consequences of their behavior with them. (ie, they may still think their neighbor is the Devil, but be convinced that it would not be in their best interest to break his windows.)
- When clients come in with multiple problems, try to find a common theme, then tackle the theme. Similarly, try to see if there’s a single problem which is causing all the others, then tackle that. (ie, multiple problems caused by root “fear of social interaction.”)
- You don’t need to solve ALL the problems. Once the major crises are resolved and the client has a handle on CT techniques and can use them on their own, they’re good to go. Other stuff will come up, but the important thing is that now they’re equipped to handle it.
- Experimentation: teach clients to figure out what their negative thoughts are (if it’s not obvious) by recording thoughts before and during moments of anxiety/depression. Journaling is good for this. Eventually, patterns will emerge. Once the thoughts have been moved to conscious awareness, you can discuss whether or not they’re valid. Simply learning to observe one’s own thoughts often creates distance, which lessens the emotional impact. (This is the core of the mindfulness-based approach.)
- If they don’t see how thoughts are unrealistic in conversation or if it’s not sinking in emotionally, they can test their thought-hypotheses via real-world experimentation. (Is it really true that going to the party will be the worst experience ever?)
- Discuss the worst that can happen. Some negative thoughts do involve real possibilities. But in depressed people, the worst outcome is assumed to definitely happen, and goes way beyond bad stuff that could realistically happen. You want people to think, “My speech might be awesome, or average. But if it’s terrible, the worst that will happen is I’ll be embarrassed for a few days and that will suck, but it’s unlikely to affect my job and my husband will be very sympathetic,” rather than, “My speech will definitely be terrible, and I’ll get fired, and everyone will scorn me, and I will be humiliated forever.”
- Cognitive-behavioral interventions for depression: schedule activities. Have client rate activities for feelings of pleasure and mastery (accomplishment.) Consider alternative explanations and alternative actions. Cognitive rehearsal (imagine yourself doing stuff successfully.) Homework: experiments, log of automatic thoughts.
Cognitive Therapy and the Emotional Disorders
no subject
Yesyesyesyes. This is so important.
"Depressed/anxious people often think everything relates to them: if someone glances their way, it proves the person hates, scorns, or is laughing at them."
This is an ongoing biggie to me. In fact, I just this morning managed to relax about something I'd been worrying about for over 20 years. Seriously. An officemate switched offices from sharing mine to sharing somebody else's. I've been worrying (off and on, obviously) about why she didn't like me. It only this morning occurred to me that it wasn't about me. That very likely she switched offices because she really liked the other person, and that what she felt (if anything) about me was not part of the decision.
The MoodGym site (i love that site; must go back and do more) calls this "mindreading". It's handy to have a label.
I <3 Beck. I also really heart Martin Seligman's What You Can Change and What You Can't, which really changed my life; Americans tend to make every single thing their own personal responsibility (or the personal responsibility of the other person), and the book is fabulous about what sorts of issues there are options for and what not. He, by the way, comes down firmly on the side that, in most cases, you can't change your weight, and there's science to back that.
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"Everything is not about you" was seriously the single best insight I got from CT. It sounds obvious, but it isn't.
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When clients come in with multiple problems, try to find a common theme, then tackle the theme. Similarly, try to see if there’s a single problem which is causing all the others, then tackle that.
I wonder whether it would be useful to use a technique I've been taught for teaching classical riding (where students often come with many years, if not decades, of bad habits, and can get very emotional about things, and also often are resistant to change): My teacher would always pick one major, fundamental issue - the thing that was holding the student back most - and one issue where you could make good progress in a relatively short period of time. I find that the obvious progress reinforces trust - if the method can be seen to work, the willingness to invest more time and effort to make major changes is much greater.
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It's weird reading this after your post about your teacher who thinks it's terrible.
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I did not have the emotional strength to try to disentangle this or even to stay in that particular conversation more than ten seconds after she said that. And I'm still finding it surprisingly hard to get into words why the difference between "these thoughts are unrealistic and causing you unnecessary suffering" and "your thoughts are wrong" is so profoundly important.
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Also try this: http://moodgym.anu.edu.au/welcome
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(I found it very American in places, but that didn't make it any less useful.)
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PS. You are added to DW.
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My general impression remains that, for me, much of the time, CT is approaching from the wrong direction. I tend to think that the habitual thoughts are manifestations of deeper beliefs which come from an understanding of how the self/the universe/emotions interact, and I'm therefore less interested in the habitual thoughts than I am in that deep-down understanding. So I'll want to get there as quickly as is comfortably possible. Examining habitual thoughts feels to me like a possible means of doing so, but I can see so many ways that a person's deep-down understanding could put the technique to its own devices without actually changing.
But... as I said, it's been a while since I've read up on it, and you've found CBT super-helpful. What am I missing?
no subject
That being said, I have theories:
1. It works for people for whom understanding isn't the problem.
What I see in stories of people who had CT work for them well or spectacularly is that they already had insight. Maybe not perfect insight. But enough insight. What they lacked was the knowledge of how to translate insight into change.
I didn't know all the details of exactly how all my childhood issues connected to all my current problems. But I was pretty clear on the overall picture: horrifying trauma as child = psychological disaster area as adult. So for me, therapy that exclusively dug into the past was annoying and frustrating (and, I realize now, re-traumatizing, since I don't think the random therapists I found knew much about trauma), because I already had a general understanding of what happened in the past and how it connected with the present. What I needed to know was what to do about it.
I'd say, "I know what happened and how it affected me. But what do I do about it now?"
They'd then either tell me I was rushing or say that I needed more insight or that I was trying to avoid talking about painful stuff. I'd then get frustrated and quit.
CT was the first therapy which actually offered me direct tools for change. Also, it actually does deal with the roots of problems, to some extent, just not in as much detail as some other therapies do.
In theory, if I'd stuck it out with insight-based therapy, maybe I would have eventually gotten to the same point. But CT gave me tools that made me feel better much faster, and that convinced me that change really was possible and motivated to continue.
2. I don't think it literally changes thoughts all that much. I think it changes people's relationship to their thoughts and, as an extension, their concepts of their minds and their selves and reality. That's actually pretty deep. It's just a type of deep that deals more with the present than with the past.
3. It's good for people with extreme problems that need help right now. It's not the only thing that works that way, but I think people in those situations might benefit more from CT first and psychodynamic later than the reverse. It was something that saved my life and made me a functional person in a fairly short time, which then enabled me to gain greater insight later. If someone's drowning, you want to throw them a rope first and teach them to swim later.
That being said, I don't think it's the only thing that works that way - I assume you've done fine with suicidal clients and other clients in extreme crisis.
How do you use a psychodynamic approach to deal with pressing crises and people whose lives have completely fallen apart?
no subject
But my general approach seems to be: "Okay, hi, what are the problems you're dealing with? Right, let's explore this. Here are some skills for identifying and preventing panic attacks/alternate activities to cutting/methods of grounding/methods of relaxation/steps you can take to get out of your terrible housing situation/ways you can deal with the paperwork to get yourself on disability/etc!
"Did that work?
"No? Okay, interesting. Let's look deeper at why not. (And also, here are some other things you can try.)"
My feeling is that it'll be most useful to get someone out of their most immediate crisis before we start looking deep. In no small part because in order for the deep digging to work well, they need to know me enough to trust me some. So we'll look at behavioral changes they can make first, but the point of it is immediate stabilization, demonstration of therapy as something that can make them feel better, and establishing rapport between us.
And, I mean, I check in-- if someone's been in therapy for three months and their initial symptoms are gone, I'll ask them if they'd like to stop. But I haven't yet had anyone take me up on it.
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If anyone had ever done any of that, I would have stuck around.
Until I found the CT therapist, I managed to find a whole series of therapists who started with "Let's talk about your feelings about your childhood/your parents and how they are influencing your feelings now," continued with "let's talk about your feelings (etc) some more," and never gave me anything else.
I actually did end up talking quite a lot about the past and my feelings. But not until I was stabilized. She was the only person who didn't skip the stabilization. And since the popular image of therapy is "talk about your feelings," I didn't realize that there was a problem with the therapists. I assumed that I was a hopeless case.
no subject
I mean... I don't think that what I do falls, strictly speaking, under any of the major psychodynamic theories. I'm not sure what really effective psychodynamic therapists do with people in crisis.
Although it may have to do with something strange: I feel that most people who say "let's talk about your feelings" don't actually do enough of, um, talking about feelings. They talk about events, and people's beliefs about the events, and maybe relationships, and maybe symptoms. But there's not nearly enough of the "oh, hey, this is what anger feels like physically. This is what you can use anger for, and what its function is. What do you do with anger?"
no subject
Say more about this?
This is the mindfulness-based approach
But I think the lasting change comes from people gaining the understanding, on the rock-bottom level that only comes from experiencing it for themselves over and over, that thoughts (and feelings) are not reality, not the self, and not permanent. The self is the pond; thoughts and feelings are ripples on the pond. Just because you feel that something is true doesn't mean it literally is true.
I think a lot of problems stem from or are exacerbated by the belief/feeling that negative feelings last forever an represent the literal truth about one's self and the world. Being sad and scared is terrifying and awful if you think you'll always feel that way, and the fact that you're sad and scared means that something terrible is going on.
But if you've spent a long time looking at and interrogating your thoughts and testing them against reality, you get an intuitive sense that emotions are real, but transient, and may not be based on any sort of literal truth. If you have that sense, you still have negative and dysfunctional thoughts and emotions (hopefully fewer of them), but you can tolerate them way, way better.
In short: I think CT is really about learning to tolerate negative emotional states. It's just easier for lots of people to work on emotions via thoughts than on emotions directly. And once you learn to tolerate negative emotional states, they bother you less, and then you have those states less.
Re: This is the mindfulness-based approach
Yeah! This makes a lot of sense to me.
I think CT is really about learning to tolerate negative emotional states. It's just easier for lots of people to work on emotions via thoughts than on emotions directly. And once you learn to tolerate negative emotional states, they bother you less, and then you have those states less.
That is what psychodynamic work is really about, too! I think. The approach I take is very much about understanding your feelings enough that they're not scary, that you don't get stuck in emotions, that you don't think of them as permanent truths about the universe just because they're what you learned when you were small. Which are some important differences, and it sounds like CT does more reality-testing and seeing reality as worth paying attention to over how you feel about it. But there's a real similarity, too, in the whole "Feelings: they won't actually kill you," sense.
I'm not sure how much of this overlap is because I've also studied (and found super-useful) a bunch of mindfulness-based stuff, and how much it's just that this is what therapy is for? But cool.