Chapter 15: Ellis and Beck: Cognitive-Behavior Therapy and Acceptance Therapy

Part 3: 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 percent 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, and emotional suffering. As a result, they lack motivation, and 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).

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
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 clients 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.

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?

Personality Theory in Real Life:  Beck’s Cognitive Therapy and the Treatment of Personality Disorders

Aaron Beck and a number of his colleagues, as well as others, have attempted to apply cognitive therapy to the treatment of personality disorders.  It is widely accepted that personality disorders are highly resistant to treatment, but aside from the problems they present by themselves, there is another important reason to continue trying to address these serious psychological disorders.  Personality disorders often co-occur with other psychological conditions, and they may be the primary reason why psychotherapy does not work well with certain patients (Pretzer & Beck, 2005). Since cognitive therapy, in particular, requires that the therapist gain an understanding of what the client is thinking in order to then help the client recognize their own dysfunctional cognitions so that the client may work toward change, it is necessary for the therapist to have a complete understanding of the client’s psychological make-up.  As a prelude to treating personality disorders with cognitive therapy, one needs to understand personality disorders in cognitive-behavioral terms.

As with depression or any other psychological disorder, the cognitive-behavioral perspective suggests that individuals suffering from personality disorders have formed dysfunctional schemas that create an attributional bias, which then causes the person to interpret life’s experiences in dysfunctional ways, but in ways that nonetheless support and maintain the dysfunction of the personality disorder.  If this theory is accurate, one should be able to identify typical patterns of dysfunctional schemas that match the characterization of different personality disorder diagnoses. Indeed, Beck and Freeman (1990) have offered those patterns in Cognitive Therapy of Personality Disorders.  What distinguishes the negative schemas that characterize personality disorders from schemas that characterize other psychological disorders reflects the basic difference between personality disorders and other disorders listed in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-5):

The typical schemas of the personality disorders resemble those that are activated in the symptom syndromes, but they are operative on a more continuous basis in information processing.  In dependent personality disorder, the schema “I need help” will be activated whenever a problematic situation arises, whereas in depressed persons, it will be prominent only during the depression.  In personality disorders, the schemas are part of normal, everyday processing of information. (pg. 32; Beck & Freeman, 1990)

What might the typical schemas associated with other personality disorders be?  Beck and his colleagues offer detailed examples for all ten of the personality disorders listed in the DSM, as well as for the passive-aggressive (negativistic) personality disorder (Beck & Freeman, 1990; Pretzer & Beck, 2005).  To cite just a few examples, the antisocial individual thinks that “people are there to be taken,” the narcissistic individual thinks “I am special,” and the histrionic individual believes “I need to impress.” As a result of these basic beliefs and attitudes, these individuals adopt corresponding behavioral strategies.  The dependent person seeks attachment, the antisocial person attacks, the narcissist engages in self-aggrandizement, and the histrionic person performs dramatically (Beck & Freeman, 1990).

How does a personality disorder arise, according to the cognitive-behavioral perspective?  First, there are inherited predispositions that may represent primeval strategies. For example, Beck has suggested that the antisocial personality reflects a predatory strategy, whereas in contrast, the paranoid personality reflects a defensive strategy (see Pretzer & Beck, 2005).  Second, the characteristics of personality disorders can result from social learning, especially when the social environment enhances genetic predispositions. A child born with a shy disposition, in a household that seems threatening and/or confusing, may naturally withdraw. That withdrawal, taken to its extreme, is a strategy compatible with the avoidant personality disorder.  And finally, there is the possibility of traumatic experiences during development. Personality becomes well established during childhood. If one’s experiences during this important time are dysfunctional and traumatic, the individual is likely to develop a personality that has ingrained dysfunctional schemas, thus affecting the individual’s life from that point forward. In this model, personality disorders are not necessarily any different in form than other psychological conditions, but since they directly involve one’s relationship with others, they become significant, problematic features of one’s daily life:

…The cognitive view of “personality disorder” is that this is simply the term used to refer to individuals with pervasive, self-perpetuating cognitive-interpersonal cycles which are dysfunctional enough to come to the attention of mental health professionals. (pg. 61; Pretzer & Beck, 2005)

The basic approach to treating personality disorders with cognitive therapy is not different than usual, but does require some special attention to detail:

Personality disorders are among the most difficult and least understood problems faced by therapists regardless of the therapist’s orientation.  The treatment of clients with these disorders can be just as complex and frustrating for cognitive therapists as it is for other therapists…For cognitive therapy to live up to its promise as an approach to understanding and treating personality disorders, it is necessary to tailor the approach to the characteristics of individuals with personality disorders rather than simply using “standard” cognitive therapy without modification. (pp. 44-45; Pretzer & Beck, 2005)

Based on this concern, Pretzer and Beck (2005) have offered a list of twelve key elements that require attention when using cognitive therapy to treat an individual with a personality disorder:

1. Interventions are most effective when based on an individualized conceptualization of the client’s problems.
2. It is important for the therapist and client to work collaboratively toward clearly identified, shared goals.
3. It is important to focus more than the usual amount of attention on the therapist-client relationship.
4. Consider beginning with interventions which do not require extensive self-disclosure.
5. Interventions that increase the client’s sense of self-efficacy often reduce the intensity of the client’s symptomatology and facilitate other interventions.
6. Do not rely primarily on verbal interventions.
7. Try to identify and address the client’s fears before implementing changes.
8. Help the client deal adaptively with aversive emotions.
9. Anticipate problems with compliance.
10. Do not presume that the client exists in a reasonable environment.
11. Attend to your own emotional reactions during the course of therapy.
12. Be realistic regarding the length of therapy, goals for therapy, and standards for therapist self-evaluation.

Despite these straight-forward steps toward effective cognitive therapy, it seems clear from looking at them that there are going to be challenges when dealing with clients who have a personality disorder.  Indeed, the very process of collaborative empiricism can be quite difficult with these clients. Beck & Freeman (1990) have identified nineteen problems associated with establishing an effective collaboration with clients who have a personality disorder:

1. The patient may lack the skills to be collaborative.
2. The therapist may lack the skills to develop collaboration.
3. Environmental stressors may preclude changing or reinforce dysfunctional behavior.
4. Patients’ ideas and beliefs regarding their potential failure in therapy may contribute to non-collaboration.
5. Patients’ ideas and beliefs regarding effects of the patients’ changing on others may preclude compliance.
6. Patients’ fears regarding changing and the “new” self may contribute to noncompliance.
7. The patient’s and therapist’s dysfunctional beliefs may be harmoniously blended.
8. Poor socialization to the model may be a factor in noncompliance.
9. A patient may experience secondary gain from maintaining the dysfunctional pattern.
10. Poor timing of interventions may be a factor in noncompliance.
11. Patients may lack motivation.
12. Patients’ rigidity may foil compliance.
13. The patient may have poor impulse control.
14. The goals of therapy may be unrealistic.
15. The goals of therapy may be unstated.
16. The goals of therapy may be vague and amorphous.
17. There may have been no agreement between therapist and patient relative to the treatment goals.
18. The patient or therapist may be frustrated because of a lack of progress in therapy.
19. Issues involving the patient’s perception of lowered status and self-esteem may be factors in noncompliance.

Although Beck and his colleagues offer more details and specific clinical examples in their writings (Beck & Freeman, 1990; Pretzer & Beck, 2005), the preceding lengthy list of problems a therapist is like to encounter clearly suggests that working with these clients is difficult at best.  So, is cognitive therapy effective in the treatment of personality disorders? Numerous uncontrolled clinical reports suggest that it is, but the small number of controlled studies have offered equivocal results. More important, however, is the reality of “real-life” clinical practice:

In clinical practice, most therapists do not apply a standardized treatment protocol with a homogenous sample of individuals who share a common diagnosis.  Instead, clinicians face a variety of clients and take an individualized approach to treatment. A recent study of the effectiveness of cognitive therapy under such “real world” conditions provides important support for the clinical use of cognitive therapy with clients who are diagnosed as having personality disorders… (pg. 102; Pretzer & Beck, 2005)

So what can we conclude from this discussion?  There is consensus that personality disorders are prevalent in our society and they are resistant to treatment.  Cognitive therapy, and the theory underlying it, has offered a promising avenue for further research. Given the significant impact of personality disorders on both individuals and society as a whole, any promising line of research deserves to be pursued vigorously.

Supplemental Materials

Cognitive Restructuring in CBT

This video [5:06] features Dr. Aaron Beck reviewing cognitive restructuring with a depressed client during a Beck Institute Workshop.  Dr. Beck describes how he helped the client evaluate evidence for and against his thoughts and his belief that he was a failure. He also explains how cognitive restructuring helps depressed clients access rational thinking that is typically blocked by their cognitive distortions.

Source: https://youtu.be/_dAPW9j3UW4

Origins of Dr. Aaron Beck’s Theory of Depression

This video [4:18] features Dr. Aaron Beck discussing the origins of his theory of depression.  He describes several research techniques he employed to test the psychoanalytic hypothesis that depression is caused by inverted hostility.

Source: https://youtu.be/VBPOFEw7BLw

References

Text:  Kelland, M. (2017). Personality Theory. OER Commons. Retrieved October 28, 2019, from https://www.oercommons.org/authoring/22859-personality-theory.  Licensed under CC-BY-4.0.

Beck Institute for Cognitive Behavior Therapy.  (2014, April 30). Cognitive restructuring in CBT.  [Video File]. Retrieved from https://youtu.be/_dAPW9j3UW4. Standard YouTube License.

Beck Institute for Cognitive Behavior Therapy.  (2014, July 30). Origins of Dr. Aaron Beck’s theory of depression.  [Video File]. Retrieved from https://youtu.be/VBPOFEw7BLw. Standard YouTube License.