Cognitive Therapy and the Emotional Disorders, by Aaron T. Beck, MD

[rachelmanija]

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

Comments

[mme_hardy]

"(Shoulds are generally harmful and unrealistic. Listen for them.)"

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.

[em_h]

I'm with the mindfulness approach; CT that is about changing the thoughts hasn't worked so well for me, but changing my relationship to them, YES. My own sense is that the negative thoughts are to such a large degree coming out of my slightly screwy biochemistry that I can't get too far towards changing them. But if I can understand them as to a large extent chemically-based, and keep applying as many reality checks as I can, and not get too caught up in the negativity, I can manage even when things are quite bad.

[green_knight]

I wonder how much of that is tied to life experience, though. Because once the worst *has* happened to you a few times - people close to you get recurring cancer or die in car accidents, you lose your home and you don't have enough money for a deposit to move somewhere else, you get fired two days before Christmas [fire, flood, pestilence], you *know* that you are living in a universe where not only it's a possibility for the worst to happen, but it can happen to you. Again.

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.

[ironed_orchid]

That sounds so great and so sensible.

It's weird reading this after your post about your teacher who thinks it's terrible.

[em_h]

A bit of a digression, but ... I don't think I mentioned this at the time, but during that post-ordination training session that went to absolute hell, one of the evangelicals tried to argue that the "depression is sin" approach is basically just like CT, because they're both about telling people that they're thinking the wrong thoughts.

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.

[elynne.livejournal.com]

Very interesting stuff. I've been in cognitive therapy in the past. It's good ideas, and some things I could use more of now, though I can't afford therapy and I'm reluctant to try again (after several not-terrible-but-definitely-a-waste-of-effort-and-money attempts). Ah well... I can at least read about it and see if I can make some of it work for myself!

[gaudior.livejournal.com]

This is really interesting. It's been a while since I studied CT, and I'm wondering whether now I should do some catch-up reading.

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?