19.4: Cognitive-Behavioral Therapy and Acceptance Therapy
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Albert Ellis and Aaron Beck are not known as personality theorists, but both are well-known therapists and prolific authors. Their unique approaches to therapy are, of course, based on their theoretical perspectives, each of which emphasizes cognitive processes. Thus, we will take a brief look at how they have applied cognitive aspects of personality theory to the treatment of psychological disorders.
Pretzer and Beck (2005) have suggested that cognitive therapies are truly integrative approaches that treat the individual within a phenomenological perspective. Beck was trained as psychoanalyst, and began examining his patients’ thought processes carefully in an attempt to prove that Freud was right about depression being the result of anger turned inward. However, Beck instead discovered that his patient’s thoughts focused more on themes such as despair and defeat, and that their appraisals of situations in life and their consistently negative biases in processing information were better predictors of their mood and behavior. Thus, Beck began to develop a cognitive approach to working with his patients. At the same time Ellis was developing rational-emotive therapy, and the two theories have influenced each other in many ways (Pretzer & Beck, 2005). In addition, cognitive therapy has been influenced by many other developments in the field of psychology, including the work of Freud, Adler, Horney, Rogers, Bandura, and, of course, Kelly. The integration of these various approaches, in order to truly understand the individual, requires the therapist to work actively with the client:
…The idea of “collaborative empiricism” is central to the practice of cognitive therapy. In the course of therapy, the cognitive therapist works with his or her client to collect detailed information regarding the specific thoughts, feelings, and actions that occur in problem situations. These observations are used as a basis for developing an individualized understanding of the client which provides a basis for strategic intervention…For the cognitive therapist to intervene effectively, he or she must endeavor both to understand the individual’s subjective experience and to perceive objective reality accurately. (pp. 46-47; Pretzer & Beck, 2005)
More recent developments in cognitive therapy have focused on accepting the circumstances of one’s life, doing so not as an excuse, but in order to facilitate moving forward from that point. Acceptance and Commitment Therapy (ACT) acknowledges the presence of suffering in human life, and focuses on using mindfulness to re-orient one’s relational framework to the circumstances of one’s life (Eifert & Forsyth, 2005; Hayes & Smith, 2005; Hayes, Strosahl, & Wilson, 1999). ACT has many elements in common with the traditional practice of Buddhist mindfulness, an approach that is taken directly in Radical Acceptance (Brach, 2003).
Brief Biographies of Albert Ellis and Aaron Beck
Albert Ellis was born in 1913 in Pittsburgh, Pennsylvania. When he was 4 years old his family moved to New York City, and Ellis has remained there ever since. Although Ellis considered his childhood to have had no significant effect on his subsequent career in psychology, there were some rather dramatic factors that influenced the person he became. His father was a traveling salesman who was seldom home, and when he was home he paid little attention to his children. After his parents were divorced, Ellis seldom saw his father again. His mother wasn’t much more attentive, doing very little for the children, and often leaving them home alone. Ellis later wrote: “As for my nice Jewish mother, a hell of a lot of help she was!” (cited in Yankura & Dryden, 1994). Ellis was also very sick following tonsillitis and a strep infection. He needed emergency surgery, and then developed nephritis. Over the next 2 years, from 5 to 7 years old, he was hospitalized eight times, once for 10 months. Yet his parents remained uncaring, and he would sometimes go weeks without anyone from the family visiting him in the hospital. The illness kept him from playing sports or other games even when he was home from the hospital. Perhaps as a result of all of these circumstances, or perhaps because of his temperament, Ellis was painfully shy. He dreaded public activities, such as when he won an award for his excellent academic work, and he avoided making social overtures toward any girl he had a crush on (Yankura & Dryden, 1994).
Surprisingly, Ellis grew strong from these experiences. He thrived on his independence and autonomy, and turned his attention toward his schoolwork. He obtained praise from adults other than his parents, and at one point became something of a leader amongst the children in the hospital. Although his shyness plagued him for many years, he developed a strong sense of self-esteem based on his success in academics. Most importantly, he developed a sense of choosing to overcome his adverse childhood. He did not become a strong-willed individual because of his bad childhood, for example he describes his sister as never really being happy, but in spite of it, due largely to being born with an innate capacity for rational thinking (Yankura & Dryden, 1994).
Much like B. F. Skinner, Ellis hoped to become a writer. Having finished high school at the age of 16, he decided to attend business school at the City College of New York so he might make enough money to support his writing career. However, the Great Depression was just beginning, so there was little opportunity for a young man to make money in business. Nonetheless, he wrote a great deal. He wrote a 500,000-word autobiographical novel. By the age of 28 he had written twenty full-length novels, plays, and books of poetry. None of them were published. He also wrote numerous non-fiction works on sex, philosophy, and politics. None of them were published. However, his research on the topics of sex, love, and marriage made him a popular source of advice amongst his friends. And so he decided to pursue professional training in psychology (Yankura & Dryden, 1994).
Ellis began his studies in the psychology program at Columbia University, and then transferred to the clinical psychology program at Teachers College of Columbia University, receiving a Ph.D. in clinical psychology in 1947. That year he also began training as a psychoanalyst at the Karen Horney Institute for Psychoanalysis. His training analyst was Dr. Charles Hulbeck, who had been analyzed by Hermann Rorschach. One of the personal issues Ellis addressed during his training analysis was whether or not to marry the women he had begun dating. He eventually decided not to marry her (he was later married twice, one marriage ended in annulment, the other in divorce). Ellis was successful as a psychoanalyst, but many patients couldn’t afford to come as often as was recommended in traditional psychoanalytic theory. Curiously, Ellis noticed that patients who came less often seemed to fare better in therapy, especially when the constraints of limited time caused Ellis to be more proactive in therapy. He pursued this active-directive approach to therapy, and by the mid-1950s he had developed rational emotive behavior therapy to the point where he published his first articles and began describing the technique at professional conferences (Yankura & Dryden, 1994).
Ellis devoted the rest of his career to establishing rational emotive behavior therapy as a significant force in psychotherapy. In 1959 he established the Institute for Rational Living, and by the 1980s there were similar institutes in Australia, Britain, Canada, Germany, Israel, Italy, Mexico, and the Netherlands. He has written over 75 books, beginning with How to Live with a Neurotic (Ellis, 1957), hundreds of articles, and he has received many distinguished awards. After 60 years as a psychotherapist, marriage and family counselor, and sex therapist, Ellis has been honored as a fellow of five major associations. He was recognized with the Humanist of the Year Award by the American Humanist Association, the Distinguished Psychologist Award of the Academy of Psychologists in Marital and Family Therapy, the Distinguished Practitioner Award of the American Association of Sex Educators, Counselors and Therapists, and the American Psychological Association has recognized him for Distinguished Professional Contributions to Knowledge. In a 1991 survey ranking the “Most Influential Psychotherapist,” Canadian psychologists ranked Ellis #1, whereas American psychologists ranked him second to Carl Rogers, but ahead of third-place Sigmund Freud (Ellis, 1994, 2005; Yankura & Dryden, 1994)!
In most ways, Aaron Beck’s childhood couldn’t have been more different than that of Ellis. Born in 1921, he was the youngest child of loving and supportive parents. His parents were particularly supportive of education: his brother Irving became a physician, and his brother Maurice entered social work after earning a Master’s degree in psychology (the other two children had died in childhood, his only sister dying in the worldwide influenza epidemic of 1919). Like Ellis, however, Beck was extremely ill as a child. When he was seven years old, Beck broke his arm at a playground. An infection set in, which then developed into septicemia (a generalized blood infection). At the time, septicemia was 90 percent fatal, and his brother Irving overheard the doctor tell their mother that Beck would die. Although he obviously survived, he missed so much school that he had to be held back a year. As often happens when young children are held back in school, the effect on his self-esteem was devastating, and Beck came to believe that he was stupid and inept (Weishaar, 1993; for more information on the negative effects of grade retention visit the National Association of School Psychologists’ website at www.nasponline.org).
However, with the help of his brothers, Beck was able to catch up to and eventually surpass his classmates, graduating first in his high school class. Along the way he belonged to the Audubon Society, worked as a camp counselor, became the youngest Eagle Scout in his Boy Scout troop, and was editor of the high school newspaper. He followed his brothers to Brown University, but was unsure of a career path. He majored in English and Political Science, but he took a wide variety of courses, eventually taking the courses necessary to go on to medical school. He graduated magna cum laude , Phi Beta Kappa, and won awards for oratory and essay writing. Despite his dramatic successes, Beck suffered a great deal of anxiety, particularly a blood/injury phobia that most likely resulted from his frightening experiences related to the emergency surgery necessary when he broke his arm. Having been accepted to the Yale School of Medicine, his surgery rotation was very difficult in light of his fear of blood. However, he worked through his fears cognitively (an obvious foreshadowing of the work that would make him famous), and successfully completed his medical degree (Weishaar, 1993).
Beck never intended to study psychiatry, and thought little of psychoanalysis. However, having graduated in 1946, there were many veterans returning from World War II. In 1949, he began a residency in neurology at a veteran’s administration hospital in Massachusetts. Due to a pressing need for psychiatrists, the director of the program began requiring everyone to complete a rotation is psychiatry. The psychiatry program at the hospital was primarily influenced by the Boston Psychoanalytic Institute, and Beck protested that psychoanalytic formulations seemed far-fetched, but he eventually decided to stay in psychiatry and to study psychoanalysis in greater detail. He first studied psychoanalysis at the Austin Riggs Center in Massachusetts, where one of his supervisors was Erik Erikson. After completing his training in psychiatry, he joined the faculty of the University of Pennsylvania Medical School (in 1954), where he has remained ever since. As he began his research career, Beck intended to confirm Freud’s hypothesis that depression was the result of hostility turned inward. However, he began to recognize that his patients were greatly influenced by underlying patterns of cognition, the so-called automatic thoughts that are so well-known today. About this same time, Beck learned of Kelly’s work on personal constructs (which Beck later referred to as schemas). As a result of these ideas and experiences coming together, Beck’s own cognitive theory began to take shape. Then, in 1963, Ellis read an article written by Beck. Ellis sent copies of his own work to Beck, and reprinted Beck’s article in the journal Rational Living . Beck then invited Ellis to speak to the psychiatry residents at Penn, and from that point forward the two maintained close contact. Beck has credited Ellis as being an excellent spokesperson for cognitive approaches to psychotherapy (Weishaar, 1993).
During his career, Beck has received many awards, including the Distinguished Scientific Award for the Applications of Psychology from the American Psychological Association. He has also received major awards from the American Psychiatric Association, the American Psychopathological Association, and the American Association of Suicidology. He received an honorary doctorate in medical science from his alma mater, Brown University, in 1987 he was elected a Fellow of the Royal College of Psychiatrists (England), and he is a senior member of the Institute of Medicine. Perhaps the most meaningful tribute, however, is that his daughter, Dr. Judith Beck, has followed in his footsteps. She is currently the Director of the Beck Institute for Cognitive Therapy and Research, and a Clinical Associate Professor at the University of Pennsylvania. She has written a number of books on cognitive therapy and, with her father, developed the Beck Youth Inventories (for more information visit the website for the Beck Institute for Cognitive Therapy and Research at www.beckinstitute.org).
Placing Ellis and Beck in Context: Cognitive Therapy
In one sense, Ellis and Beck do not belong in a book about personality theory. They are not known for their theoretical contributions to our understanding of personality development. In another sense, they are among the most important theorists covered, since the practical application of cognitive theories to psychotherapy has had a dramatic influence on the effectiveness of psychotherapy in treating psychological disorders. Remember that Freud, as well as most of the other well-known psychodynamic theorists, began conducting therapy first and later developed theoretical perspectives which helped to explain what they saw in their patients and what worked in therapy. Similarly, Ellis and Beck focused on the development of their therapeutic approaches, and to a large extent their theoretical perspective is inferred from the techniques they use in therapy.
In addition, one could argue that the cognitive therapies of Ellis and Beck stand at the pinnacle of the behavioral and cognitive theories of personality that have been so influential in American psychology. As evidence of their significance, Beck received an Albert Lasker Clinical Medical Research Award in 2006. Often called the American Nobel Prize (some seventy recipients have gone on to win a Nobel Prize), in the 60 years that the Lasker prizes have been awarded, Beck is the first psychotherapist to be honored. This award is a testament both to the respect that cognitive psychotherapy has earned in the medical community and to Beck for the honor he has earned amongst many ground-breaking psychotherapists.
Although cognitive therapies may seem highly specialized, both Ellis and Beck drew upon many different areas of psychology and psychiatry, as well as Eastern philosophies, while developing their techniques. Their psychoanalytic training exposed them to the directive approach of Adler and to Horney’s emphasis on the (which can be viewed as a neurotic belief or a type of automatic thought). In addition, they cited theorists, authors, and spiritual leaders such as Bandura, Frankl, Rogers, Piaget, the Dalai Lama, D. T. Suzuki, Lao Tsu, Jesus of Nazareth, and many others. The range of ideas that Ellis and Beck synthesized into a cohesive and direct approach to psychotherapy is unparalleled in the fields of psychology and psychiatry.
Rational Emotive Behavior Therapy
In order to understand Ellis’ perspective on therapy, one must first understand his perspective on the basis of psychological disturbances, whether they are minor problems with personal adjustment or more serious forms of mental illness. Individuals with problems typically have a long history related to the disorder. Using the same example as Ellis (1957), suppose a woman is chronically depressed because she has been rejected by men she really liked and with whom she wanted to have long-term relationships. She understandably concludes that the activating event of being rejected leads to the consequence of being depressed. However, this conclusion is wrong! According to Ellis, it is not the rejection that causes her depression, it is the belief system that arises within her, particularly irrational beliefs, that cause her depression. For example, if she rationally believed that it was unfortunate that someone she liked rejected her, or that it was frustrating that she was rejected, she might not become depressed. However, if she irrationally believes that it is awful that she has been rejected, or that she should have been more beautiful so that he wouldn’t have rejected her, then she is quite likely to become depressed. This is what Ellis referred to as the A-B-C’s of emotional disturbance or self-defeating behaviors and attitudes. A refers to the activating event (being rejected), B refers to the person’s beliefs(this is awful, I’m not pretty), and C is the consequence of the beliefs: depression. The basis for therapy in such situations can be found by extending the A-B-C’s to the D-E’s: disputing (D) the irrational beliefs, which hopefully leads to the cognitive effect (E - effective new philosophies, emotions, and behaviors) of disrupting the self-defeating patterns of behavior (Ellis, 1957, 1973, 1996). More recently, Ellis has proposed one more letter for his ABC theory of personality , the letter G for goals (*note: there is no “F”). Goals consist of a person’s purposes, values, standards, and hopes. When these goals are thwarted by an activating event, the person can respond by choosing healthy or unhealthy alternatives, and the nature of that choice is based on one’s beliefs (Ellis, 1994). Ellis considered the ABC theory to be so straightforward that it could prove helpful to anyone.
When an individual has become trapped by unhealthy belief systems and the corresponding self-defeating behavior patterns that accompany them, the potential need for psychotherapy arises. The therapy that Ellis developed has come to be known as rational emotive behavior therapy , or REBT (the name went through several permutations over Ellis’ career, and he finally settled on REBT). The primary task of the therapist using REBT is to challenge the client’s irrational beliefs and, in so doing, to help the client change their belief systems. In essence, when the client believes that it would be catastrophic for a certain negative outcome to occur, the therapist tries to help them by disputing the irrational belief with questions such as: “Why would a certain outcome be catastrophic?” While trying to dispute the irrational beliefs, the therapist also searches for underlying philosophies that support the irrational belief system, philosophies that can then also be disputed. In addition to the cognitive aspect of REBT, the therapist often encourages the client to act against their irrational fears. If the client is willing, they have the opportunity to experience anxiety-ridden situations without the catastrophic consequences they have feared (although the help of the therapist may prove necessary along the way). Throughout this process, REBT does not intend to ignore the person’s feelings. However, when a client is suffering from unhealthy and self-defeating feelings, such as anxiety, depression, or anger, REBT can help to minimize those unhealthy feelings. In addition, REBT encourages healthy, positive emotions, and recognizes that sometimes a strong negative response, such as sadness or grief, to a tragic activating event may be healthy or constructive. When utilized effectively, REBT offered what Ellis believed was a better, deeper, and more enduring therapy, which could achieve those results in a fairly brief amount of time (Ellis, 1962, 1973, 1994, 1995, 1996). Ellis also believed that REBT was applicable to a wider range of clients than any other psychotherapy:
RET [later known as REBT], on the contrary, seems to be almost the only major kind of psychotherapy (aside, perhaps, from Zen Buddhism, if this is conceptualized as psychotherapy…) that holds that the individual does not need any trait, characteristic, achievement, purpose, or social approval in order to accept himself. In fact, he does not have to rate himself, esteem himself, or have any self-measurement or self-concept whatever. (pg. 65; Ellis, 1973)
First and foremost, Ellis focused on practical applications of psychotherapy, and he considered his approach to be humanistic in its emphasis on the whole person. He acknowledged that REBT shared important elements with the approaches of other classic theorists who had emphasized the value of individuals, including Alfred Adler, Viktor Frankl, Rollo May, Carl Rogers, Abraham Maslow, and Karen Horney (Ellis, 1973, 1995). Ellis’ discussion of the practice of REBT seems to focus on what Horney addressed in her concepts of neurotic needs and the tyranny of the should. Taken together, the desire to focus on practical applications and helping individuals has led to a wide variety of self-help books based on REBT (Yankura & Dryden, 1994). Naturally, this list includes many books by Ellis himself, including titles such as How to Live With a Neurotic (Ellis, 1957), A New Guide to Rational Living (Ellis & Harper, 1975), How to Live With - and Without - Anger (Ellis, 1977), How to Cope With a Fatal Illness (Ellis & Abrams, 1994), How to Keep People from Pushing Your Buttons (Ellis & Lange, 1994), How to Control Your Anxiety Before It Controls You (Ellis, 1998), and Sex Without Guilt in the 21st Century (Ellis, 2003). REBT has also been applied to a wide variety of other problems that have been covered in Ellis’ books, such as marriage counseling, personality disorders, depression, and even schizophrenia, and REBT has proved successful in both individual and group settings (Ellis, 1962, 1973, 2001; Ellis & Dryden, 1987).
Discussion Question 1
Rational emotive behavior therapy is based on the ABC theory of personality. Can you think of situations in which activating events led you to specific consequences, even though your beliefs, if you thought about them enough, were the real reason for the consequence you experienced?
Ellis, as well as other therapists using REBT, has also addressed addictive disorders, including alcoholism (Ellis, 2001; Ellis, McInerney, DiGuiseppe, & Yeager, 1988; Trimpey, Velten, & Dain, 1993; Yeager, Yeager, & Shillingford, 1993). In the early 1990s, Rational Recovery (RR) was developed by Jack Trimpey as an alternative to the Alcoholics Anonymous (AA) approach to treating alcohol abuse. Both Ellis and Trimpey challenge the basic principles of AA: that the addict has no control over their alcohol cravings, that they must turn over control to a higher power (such as God), that they can never drink alcohol again, and that only AA works for alcoholics. Objective research simply does not support these assertions, and practitioners of REBT and RR have great faith in the ability of individuals to take control of their own lives (though they may need some help from a therapist to get on the right path). RR also does not include the strong religious overtones of AA, which may be an impediment to recovery for anyone required to attend AA meetings but who does not believe in God:
…The core of these methods is learning to recognize and dispute self-defeating thinking that RR frequently labels “the Beast” or “the addictive voice.” In addition to its treatment purposes, RR has a political purpose in advocating for people who are mandated to attend spiritual healing groups but who find that approach useless or offensive. Furthermore, RR attempts to educate professionals about available options and sensitize them to the ethical and possible legal issues involved in overriding client’s objections to spiritual healing approaches. (pg. 271; Trimpey, Velten, & Dain, 1993)
Since REBT focuses on the choices that individuals make for themselves, what role is there for religion within such a perspective? Ellis maintains that there is a significant positive correlation between devout religious beliefs and a variety of emotional disturbances. However, he has argued that the problem is not religion per se , but rather highly restrictive, dogmatic religiosity that causes problems for an individual (Ellis, 2004; also see Yankura & Dryden, 1994). Ellis studied the works of Lao Tsu (author of the Tao Te Ching ), Gotama Buddha (known by most people simply as the Buddha), and the existential theologian Paul Tillich, finding helpful perspectives for working with his clients and on his own problems (Ellis, 2004). He overcame his early objections to religion and spirituality by recognizing that when one’s religious beliefs contribute to good psychological health the belief itself, regardless of whether or not God exists, is helpful. Similarly, Zen Buddhism is not actually a religion, but has significant religious overtones. Nonetheless, Ellis was impressed by the effectiveness of Zen meditation for many clients, so he incorporated various Eastern perspectives into the development of REBT.
Discussion question 2
Alcoholics Anonymous has helped many people, but it doesn’t help everyone, especially those who are opposed to religiosity or are simply atheists. Nonetheless, the AA approach has become a standard recommendation in many legal jurisdictions when someone commits a crime such as drunk driving. What do you think about Rational Recovery (based on REBT ) as an alternative to AA?
Is Self-Esteem a Sickness?
The heading for this section is the title of the first chapter in a fascinating book by Ellis: The Myth of Self-Esteem (Ellis, 2005). Ellis believed that self-esteem is defined by psychologists in a way that requires individuals to rate, or judge, themselves. This may work fine when everything is going well for the person, but people are not perfect. Thus, they will eventually fail at something, perhaps at many things, and they must then judge themselves as bad, or unworthy. If, however, you accept yourself as imperfect, and rate only your behaviors and thoughts, not your self, then you need not suffer from the effects of low self-esteem. In other words, Ellis advocates unconditional self-acceptance, a very old philosophy known to the Greeks, Romans, Buddhists, Daoists, and others (Ellis, 2005). Ellis considers many different approaches to the concepts of self-esteem and self-acceptance, including the perspectives of Solomon, Jesus of Nazareth, the existential philosophers Kierkegaard, Heidegger, and Sartre, Carl Rogers, the Eastern philosophers Lao Tsu, D. T. Suzuki, and the Dalai Lama, and Steven Hayes (founder of Acceptance and Commitment Therapy, see below). Ellis concludes that one must seek not only to unconditionally accept oneself, but also to unconditionally accept others and the nature of life itself. But this is not a pie-in-the-sky philosophy. Ellis recognizes that there are sad and unfortunate events in life (we are fallible, and we are mortal). He strongly recommends that we do not avoid normal sadness and regret, since these emotions provide the motivation for trying to prevent unfortunate events and for seeking new relationships. The choice is yours:
Both self-esteem and self-acceptance, then, can be had definitionally - for the asking, for the choosing. Take one or the other. Choose! Better yet, take no global rating. Choose your goals and values and rate how you experience them - well or badly. Don’t rate yourself, being, entity, personality at all. Your totality is too complex and too changing to measure. Repeatedly acknowledge that .
Now stop farting around and get on with your life ! (pg. 16; Ellis, 2005)
Discussion question 3
Ellis opposes the concept of self-esteem because he believes it requires a person to judge themselves. He advocates instead that we unconditionally accept ourselves, faults included. Does this make sense to you?
Beck’s Cognitive Model of Depression
Having begun his research in an attempt to examine Freud’s theory on the cause of depression, Beck continued studying depression and suicide throughout his career. The reason for this continued focus was the prevalence of depression in society:
Depression is the most common psychiatric disorder treated in office practice and in outpatient clinics. Some authorities have estimated that at least 12 per cent of the adult population will have an episode of depression of sufficient clinical severity to warrant treatment. (pg. vii; Beck, 1967)
Relying on an interplay between clinical work and research, Beck proposed a cognitive model based on automatic thoughts, schemas, and cognitive distortions (Beck, 1967; Beck & Freeman, 1990; Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 1995; Pretzer & Beck, 2005). Automatic thoughts are an individual’s immediate, spontaneous appraisals of a given situation. They shape and elicit a person’s emotional and behavioral responses to that situation. Since they are automatic, they are rarely questioned. Even when they are predominantly negative, the individual accepts them as true and can be overwhelmed by constant questions and images that hurt one’s self-esteem (questions such as “Why am I such a failure,” or seeing oneself as ugly). The reason that even highly negative automatic thoughts are accepted, even when they might be objectively untrue, is that these thoughts do not arise spontaneously. Rather, they are the result of the person’s schemas. Every situation is comprised of many stimuli, and when confronted with an unfamiliar situation a person tends to conceptualize it. Although different people will conceptualize the situation differently, each individual will be consistent. These stable cognitive patterns of interpreting situations are known as schemas. An individual’s schemas then determine how they are likely to respond, automatically, to many situations.
People are also prone to a variety of cognitive distortions, which can amplify the effects of one’s schemas, thus helping to confirm maladaptive schemas even when contradictory evidence is available. Over time, Beck and his colleagues have identified a growing number of such distortions, such as: dichotomous thinking , or seeing things as only black or white, without the possibility of shades of gray; personalization , the tendency to interpret external events as being related directly to oneself; overgeneralization , the application of isolated incidents to either all or at least many other situations; and catastrophizing , treating actual or anticipated negative events as intolerable catastrophes, even though they may be relatively minor problems. Overall, these cognitive distortions lead the individual into extreme, judgmental, global interpretations of the situations they experience, which establish general schemas, which lead to automatic thoughts and feelings that support the idiosyncratic experience of the world (Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 1995; Pretzer & Beck, 2005). The goal of cognitive therapy, therefore, is to help the individual break out of this self-supporting, maladaptive pattern of cognition.
Another important aspect of the depressive syndrome is known as the cognitive triad , three cognitive patterns that cause the person to view themselves in a negative manner. First, the individual has a negative view of themselves. Primarily, the depressed individual sees themselves as defective in some psychological, moral, or physical way, and because of the presumed defects they are undesirable and worthless. Second, the depressed person has a tendency to interpret their ongoing experiences in negative ways. These negative misinterpretations persist even in the face of incompatible evidence. And finally, they tend to hold a negative view of the future. They anticipate continued difficulty, failure, emotional suffering. As a result, they lack motivation, they become paralyzed by pessimism and hopelessness. According to Beck, suicide can be viewed as an extreme attempt to escape problems that depressed individuals believe cannot be solved and the unbearable suffering that the future holds! These negative cognitive patterns are not something that the depressed person plans or has much control over, since they typically occur in the form of automatic thoughts (Beck, 1967; Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 1995; also see Beck, Resnick, & Lettieri, 1974).
Discussion question 4
Beck described a number of common cognitive distortions, including dichotomous thinking, personalization, overgeneralization , and catastrophizing . Think about situations in your own life when you made these distortions. What sort of problems resulted from these cognitive errors, and how often do you make them?
Beck’s Cognitive Therapy
Cognitive therapy, according to Beck, “is an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders” (Beck, Rush, Shaw, & Emery, 1979). With regard to depression, it is most effective after a major depression has lifted somewhat, though it can also be helpful for some patients during depression, particularly if the depression is of the reactive type (as opposed to endogenous depression; Beck, 1967). As mentioned above, the basic procedure is to help the individual break out of the trap of negative schemas, automatic thoughts, and cognitive distortions that support the client’s problem. The techniques employed are designed to identify, test the reality of, and correct the cognitive distortions and schemas that lead to dysfunctional automatic thoughts. It involves an active collaboration between the therapist and the client, such that the client learns to reduce their symptoms by thinking and acting more realistically.
Beck referred to the constant interaction between the client and the therapist as collaborative empiricism , and contrasted this approach to both psychoanalysis and client-centered therapy. His intention was to provide the client with a series of specific learning experiences that would teach the patient the following skills: (1) monitoring their own negative, automatic thoughts; (2) recognizing the connections between thought, emotion, and behavior; (3) examining evidence for and against their cognitive distortions; (4) substituting reality-based interpretations for their cognitive distortions; and (5) learning to identify and alter the dysfunctional schemas that lead to the cognitive distortions (Beck, Rush, Shaw, & Emery, 1979). The interaction with the client is not superficial, as it involves discussing the very rationale of the therapy to the patient and, ultimately, providing the client with techniques to monitor their dysfunctional thoughts on their own. The therapist teaches the client to recognize the nature of cognition, particularly the client’s dysfunctional cognitions, all with the goal of eventually neutralizing the automatic thoughts. Somewhat related to collaborative empiricism is the concept of guided discovery . Guided discovery is the process by which the therapist serves as a guide for the client, in order to help them recognize their problematic cognitions and behaviors and also help them design new experiences (behavioral experiments) in which they might acquire new skills and perspectives (Beck & Weishaar, 1995). In addition, the therapeutic relationship provides an opportunity for the client to begin to make progress:
If the patient begins to feel better after the expression of feeling, this may then set up a favorable cycle. Since the depressed patient may have lost hope that he would ever be able to feel better again, this positive experience helps to restore his morale and also his motivation to cooperate in the therapy. Any evidence of feeling better is likely to increase the patient’s motivation for therapy and thus contribute to its efficacy. (pp. 43-44; Beck, Rush, Shaw, & Emery, 1979)
Although Beck focused much of his research on depression, cognitive therapy can be used to treat a wide variety of psychiatric and psychological disorders, including anxiety disorders, phobias, substance abuse disorders, anger and violence, and personality disorders (Beck, 1999; Beck & Emery, 1985; Beck & Freeman, 1990; Beck & Weishaar, 1995; Beck, Wright, Newman, & Liese, 1993; Pretzer & Beck, 2005). In Love is Never Enough (Beck, 1988), Beck extended cognitive therapy to working with couples. He had observed that many of his depressed client’s were in troubled relationships, and in other cases his client’s depression and/or anxiety had led to relationship problems. As Beck began working with couples, he found that couples were capable of the same cognitive distortions that individuals make, as each party within the relationship began focusing on the negative aspects of the relationship. As conflict grows, the partners blame each other, rather than seeing the conflict as a problem that can be resolved. Just as with individuals, cognitive therapy offers a means for breaking the cycle of conflict and miscommunication.
Discussion question 5
Collaborative empiricism and guided discovery both suggest that the client must be an active member of the therapeutic team. In your opinion, is it possible for someone who needs therapy to help in their own recovery? Do you think there is a point at which the therapist must take over in order to ensure that therapy is successful?
Acceptance and Commitment Therapy (ACT) and Radical Acceptance
A recent development in cognitive therapy shares an ancient tradition with Eastern philosophies: mindfulness. Mindfulness training involves learning to accept one’s emotional realities, and one of the most significant realities is that much of human life involves suffering. Starting with these basic observations, Steven Hayes and his colleagues have developed Acceptance and Commitment Therapy (ACT; Hayes & Smith, 2005; Hayes, Strosahl, & Wilson, 1999; see also Eifert & Forsyth, 2005; Hayes, Follette, & Linehan, 2004). Hayes and his colleagues do not mean acceptance in the sense of resigning oneself to suffering, but rather in the sense of accepting life as it comes. Then, one must commit oneself to moving forward and living a values-based life, regardless of the presence of challenges:
The constant possibility of psychological pain is a challenging burden that we all need to face…This doesn’t mean that you must resign yourself to trudging through your life suffering. Pain and suffering are very different. We believe that there is a way to change your relationship to pain and to then live a good life, perhaps a great life, even though you are a human being whose memory and verbal skills keep the possibility of pain just an instant away. (pg. 12; Hayes & Smith, 2005)
Although Hayes and his colleagues make passing reference to mindfulness as a Buddhist teaching, they do not take a spiritual approach with ACT. They do, however, acknowledge that psychologists often make the mistake of ignoring spiritual practices that might prove helpful to their clients (Hayes, Strosahl, & Wilson, 1999). Many people in psychology today, including Ellis and Beck, recognize that cognitive psychology began with the Buddha some 2,500 years ago (Ellis, 2005; Pretzer & Beck, 2005; see also Olendzki, 2005). Dr. Tara Brach, a clinical psychologist and teacher of mindfulness meditation (also known as vipassana , which means “to see clearly”), makes no qualms about following a Buddhist approach to therapy. In Radical Acceptance: Embracing Your Life with the Heart of a Buddha (Brach, 2003), Brach talks about living in a trance of unworthiness. Plagued by beliefs of their own inadequacies, some individuals limit their ability to live a full life. Consequently, they cannot trust that they are lovable, and they live with an undercurrent of depression or helplessness. They then embark on a series of strategies designed to protect themselves: they attempt self-improvement projects, they hold back and play it safe, they withdraw from the present moment, they keep busy, they criticize themselves, and they focus on other’s faults. Radical Acceptance as a therapeutic approach involves both mindfulness meditation and Buddhist teachings on compassion as a basis for teaching people to accept themselves as they are:
Radical Acceptance reverses our habit of living at war with experiences that are unfamiliar, frightening or intense. It is the necessary antidote to years of neglecting ourselves, years of judging and treating ourselves harshly, years of rejecting this moment’s experience. Radical Acceptance is the willingness to experience ourselves and our life as it is. A moment of Radical Acceptance is a moment of genuine freedom. (pg. 4; Brach, 2003)
Mindfulness as a therapeutic technique has also been used by a variety of other therapists: in couples therapy (Christensen, Sevier, Simpson, & Gattis, 2004; Fruzzetti & Iverson, 2004), following traumatic experiences (Follette, Palm, & Rasmussen Hall, 2004), and for the treatment of eating disorders (Wilson, 2004) and substance abuse (Marlatt, et al., 2004). Janet Surrey, one of the founding members of the Stone Center Group, has favorably compared relational psychotherapy to mindfulness (Surrey, 2005), and Trudy Goodman, who studied child development with Jean Piaget, uses mindfulness in therapy with children (Goodman, 2005). Thus, whether in the more structured approach of ACT or Radical Acceptance, or in more informal ways in the hands of therapists familiar with mindfulness meditation, paying attention to the mind in a calm and careful way is becoming an important trend in psychotherapy. According to Steven Hayes (2004), this approach represents a third wave in behavioral-cognitive therapy, following traditional behavior therapy and then the cognitive therapies of Ellis and Beck. This third wave is also the basis for the popular and influential work of Jon Kabat-Zinn (1990, 1994, 2005; see also Germer et al., 2005) and connects behavioral and cognitive theories to the rapidly growing field of social neuroscience (the study of the interactive influences between the structure/function of the brain and social behavior; see, e.g., Begley, 2007; Cacioppo et al., 2006; Cozolino, 2002; Harmon-Jones & Winkielman, 2007; Siegel, 1999, 2007).