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James Pretzer October 9th, 2004 09:34 PM

Is it important to change the client's dysfunctional cognitions?
It may seem to go without saying that CT's attempts to modify automatic thoughts, dysfunctional beliefs, and cognitive distortions are responsible for CT's effects and that therefore, that it is important for us to spend time in therapy working on dysfunctional cognitions. However, there are many other aspects of CT that could be responsible for its effectiveness. For example, CT includes "non-specific" factors such as the therapist's empathy and includes many behavioral interventions along with the cognitive interventions. Thus, studies that show that CT works do not necessarily provide evidence that cognitive change is important.

Studies that show that dysfunctional cognitions decrease when depressed individuals are treated with medication alone have led some to conclude that decreases in dysfunctional cognitions are an effect of decreases in depression, not a cause of decreases in depression. In fact, some (Steve Hayes comes to mind) argue that the types of changes in cognition that CT tries to accomplish are unnecessary or are counterproductive.

At this point, we have many studies that show that CBT is effective with a broad range of problems but many fewer studies that examine whether the cognitive changes that CT seeks to achieve have an important influence on outcome. Fortunately, a number of studies have been designed to examine the role that cognitive change plays in the effectiveness of CT.

In a recent study of the multidisciplinary treatment of chronic pain, Burns and his colleagues (Burns, et al, 2003) used a cross-lagged panel design to examine whether cognitive changes were a cause of improvement or an effect of improvement. They found that early-treatment changes in catastrophising and helplessness predicted late-treatment changes in outcome measures but not vice-versa. They also found that early-treatment depression changes predicted late-treatment activity changes but not vice versa. These results provide support for the hypothesis that changes in cognition are a cause of improvement rather than being a result of improvement.

In another recent study, Beevers et al (2003) examined the relationship between degree of cognitive change during treatment for depression and rate of relapse. In a sample of individuals who had achieved at least a 50% improvement in depressive symptoms, the researchers found that both a poor change in dysfunctional attitudes and a poor change in extreme thinking predicted a faster return of depressive symptoms.

Note: This isn't a systematic review, just a couple of studies I've encountered recently, but at least is gives us some support for the idea that achieving cognitive change is important.
Beevers, C. G., Keitner, G. I., Ryan, C. E. & Miller, I. W. (2003). Cognitive predictors of symptom return following depression treatment. Journal of Consulting and Clinical Psychology, 71, 488-496.

Burns, J. W., Kubilus, A., Bruhel, S., Harden, N. & Lofland, K. (2003). Do Changes in Cognitive Factors Influence Outcome Following Multidisciplinary Treatment for Chronic Pain? A Cross-Lagged Panel Analysis, Journal of Consulting and Clinical Psychology, 71, 81-91

john donohue October 24th, 2004 07:49 PM

Re: Is it important to change the client's dysfunctional cognitions?
You'r discussion of the causal connection between thinking and emotion is revealing. Upon 2nd reading it was clearer you're noted research appears to support the notion that a change of - mind (distorted thinking) may precede changes in emotion and ultimately adjustment. One thing that has impressed me over time is how slow going the use of disputation seems to be. It has occurred to me though, if George Kelley's premise is true that our constructs are layered upon a fairly rigid hiearchy, changing one habit of mind may require something akin to a seismic shift in prioritizing perception and motivation. Your note that some see CT strategies as counterproductive might be involved with this predicament of disputing the wrong layer of one's constructs and having the consequence of firming up resisitance.

James Pretzer November 6th, 2004 10:57 PM

Why is it so hard to change the client's dysfunctional cognitions?
As you suggest, there can be a variety of reasons that it is "slow going" when we try to change the client's dysfunctional cognitions. Here are a number of points that come to mind:
  1. You refer to using "disputation" to change dysfunctional cognitions. One disadvantage of using REBT-type disputation is that this tends to intensify resistance. One of the reasons that Ct emphasizes guided discovery (Socratic questioning) is that this approach tends to reduce resistance rather than intensifying it.
  2. Often, the client's dysfunctional cognitions are strongly held. In addition, the client may have had many experiences that seem to support their dysfunctional cognitions. It is not easy (or quick) to change such cognitions.
  3. Sometimes clients fear the consequences of cognitive change (i.e. "If I give up my perfectionism I'll become mediocre") and resist giving up the dysfunctional cognitions until these fears are addressed.
  4. Sometimes Cognitive therapists slip into relying solely on verbal, in-the-office interventions. CT is much more effective when verbal interventions are coupled with experiential and behavioral interventions. Behavioral experiments often are much more effective that intellectual discussion.
  5. Some dysfunctional cognitions are harder to challenge than others. A dysfunctional belief such as "If I ask for what I want, no one will take me seriously" is easy to test, "I'm unloveable" is harder to test, and "If I don't pray right, I will roast in Hell" may be quite hard to challenge effectively.
  6. ...
Obviously, I think that there are quite a few reasons that cognitive interventions may go slowly. One important time when there is "slow going" with cognitive interventions is when some other mode of intervention is more appropriate. Remember that the Thought Sheet isn't the only tool that cognitive therapists have. If the client has OCD and we try to have them generate rational responses to each of their obsessions, this is likely to be ineffective or counterproductive. Exposure and response prevention is likely to be much more effective.

There are some problems, such as depression, where we spend quite a bit of time working directly to change dysfunctional cognitions. However, there are other problems where we spend much more of our time working towards behavior change, helping clients improve their coping skills, working towards acceptance, etc.

Wayne Froggatt December 12th, 2004 08:49 PM

Re: Is it important to change the client's dysfunctional cognitions?
James, you contrast REBT-type 'disputation' with 'Socratic questioning'. However, for a good twenty years or more the Socratic method has been recommended by REBT researchers and writers as the most appropriate way to conduct disputation. The term 'disputation' is often misunderstood to mean directly contradicting or arguing with clients, which is usually counterproductive. I suspect that this misunderstanding arises partly from the use of the term 'disputation' itself. REBT continues to use it, though, because it begins with 'D' and thus conveniently fits into the ABC model. The other reason may be that the founder of REBT, Albert Ellis, tends to be rather didactic in his approach to resructuring cognitions, and practitioners who are aware of this - perhaps through seeing a video of Ellis in action - assume that all REBT therapists use the same approach. According to modern REBT, the most effective approach to disputation is Socratic.

JustBen December 14th, 2004 03:55 PM

Re: Is it important to change the client's dysfunctional cognitions?
Socrates himself would insist that these two terms ("disputation" & "Socratic questioning") be properly defined before they could be compared or contrasted. I don't have enough experience with REBT to speak to the clarity of "disputation", but the term "Socratic questioning" (and, for that matter, "Socratic method") are a hopeless muddle. Carey and Mullen do a nice job of reviewing existing "Socratic" literature in the September 2004 issue of Psychotherapy: Theory, Research, Practice, Training.

To paraphrase: existing literature does a great job of explaining the importance of Socratic questioning, but "someone wishing to learn Socratic questioning could not discern from the literature what the procedure was, when it should be used, how it should be used, or what it should be used for."

Supreme Court Justice Potter Stewart, in an opinion on pornography wrote, "I shall not today attempt further to define the kinds of material … but I know it when I see it." Unfortunately, I think many of us are satisfied to take a similar approach to the concept of Socratic questioning. This vague definition seems to satisfy, and allows us to avoid nit-picky semantic battles...and yet, it does nothing to answer some very tough questions about this Socratic questioning, namely:

When employing Socratic questioning, does the therapist guide the client to a pre-determined answer, or does the therapist simply elicit an answer already "inside" the client? (Is this technique essentially didactic or collaborative?) Are there different kinds or categories of Socratic questions?Does the term "Socratic method" encompass techniques other than questioning?

The fact that leaders in the field of psychotherapy (and even within the cognitive therapy fold) differ so dramatically in their answers to these questions raises an even meatier question: Is the research, practice, and training of psychotherapy comprimised by an inability to define terms?

Unfortunately, I think the answer to that last question is yes. It's easy to see the results of such conceptual sloppiness when you look at our approach to the currently fashionable topic of spirituality, for example. I'm willing to bet that if we asked 30 psychotherapists to define this term, we'd get 30 different answers without a single element that unites them. Yet we devote reams of paper in professional journals to the discussion of this topic as if we were all referring to some accepted operational definition.

James Pretzer January 14th, 2005 10:45 PM

Re: Is it important to change the client's dysfunctional cognitions?
It is not easy to define terms precisely and then get everyone to agree to the definition (no matter what one's theoretical orientation is) and it certainly would be a good thing if there were more of a consensus on how important terms are defined. However, I think CT is fairly clear about what we mean when we talk about "Socratic questioning" or "guided discovery."

In Cognitive Therapy of Depression (1979, pp.69-71) Beck and company say:
"Use Questioning Rather Than Disputation and Indocrination

A well-timed, carefully phrased series of questions can help the patient to isolate and carefully consider a specific issue, decision, or notion. A series of questions may open the patient's thinking around a specific issue, and thereby allow him to consider other information and experiences - either recent or past. The patient's curiosity can be raised by a series of questions. His apparently rigidly stated views become tentative hypotheses. In this way, questions are used to relieve depressed, constricted thinking.
Questions constitute an important and powerful tool for identifying, considering, and correcting cognitions and beliefs. As with other powerful tools, they can be misused or artlessly applied. The patient may feel he is being cross-examined or that he is being attacked if questions are used to 'trap' him into contradicting himself. In addition, open-ended questioning sometimes leaves the patient in the defensive position of trying to guess what the therapist 'expects' for an answer. Questions must be carefully timed and phrased so as to help the patient recognize and consider his notions reflectively - to weigh his thoughts with objectivity." (They also give three good examples of how we use questioning on pages 68-70.)
A more contemporary discussion of how we use questioning can be found in the summary of the princilpes of CT that Dr. Beck and I included in our chapter for the second edition of Major Theories of Personality Disorder (Lenzenweger & Clarkin, 2004):
"The approach used in Cognitive Therapy has been described as "collaborative empiricism" (Beck, et al., 1979, Chap. 3). The therapist endeavors to work with the client to help him or her to recognize the factors that contribute to problems, to test the validity of the thoughts, beliefs, and assumptions which prove important, and to make the necessary changes in cognition and behavior. While it is clear that very different therapeutic approaches ranging from philosophical debate to operant conditioning can be effective with at least some clients, collaborative empiricism has substantial advantages. By actively collaborating with the client, the therapist minimizes the resistance and oppositionality which is often elicited by taking an authoritarian role, yet the therapist is still in a position to structure each session as well as the overall course of therapy so as to be as efficient and effective as possible (Beck, et al., 1979, Chap. 4).

One part of this collaborative approach is an emphasis on a process of "guided discovery." If the therapist guides the client by asking questions, making observations, and asking the client to monitor relevant aspects of the situation, the therapist can help the client develop an understanding of his or her problems, explore possible solutions, develop plans for dealing with the problems, and implement the plans quite effectively. Guided discovery has an advantage over approaches in which the therapist unilaterally develops an understanding of the problems and proposes solutions in that it maximizes client involvement in therapy sessions and minimizes the possibility of the client's feeling that the therapist' ideas are being imposed on the client. In addition, since the client is actively involved in the process of developing an understanding of the problems and coming up with a solution, the client also has an opportunity to learn an effective approach to dealing with problems and should be better able to deal with future problems when they arise."
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Pretzer, J. L. & Beck, A. T. (2004). A cognitive theory of personality disorders. In: M. Lenzenweger & J. Clarkin (Eds.) Major theories of personality disorder (2nd Edition). New York: Guilford Press.

chris jones March 31st, 2005 04:37 AM

Re: Is it important to change the client's dysfunctional cognitions?
An idea that seems implicit, or "between the lines" in the notion of collaborative empiricism is that the therapist is helping the client achieve more coherent cognition - that is, thoughts that agree with more stable beliefs. ONce the client recognizes that s/he is thinking things s/he doesn't believe, there is motivation and progress...

Has this notion - of therapy as promoting coherence / reducing contradictoin - been developed explicitly by anybody in the CT literature?

James Pretzer March 31st, 2005 10:22 PM

CT as increasing coherence in the client's cognitions
This is an interesting concept that I haven't seen developed in the literature. However, there is a lot that I haven't read so I may have missed it.

The idea that the coherence (or lack thereof) of one's cognitions is what's important sounds like the sort of concept that the constructivists would like a lot. More traditional CT authors (among whom I must count myself) would argue that the point to collaborative empiricism is to test cognitions against external reality so that the client ends up with cognitions that are more realistic and incidentally are more coherent.

My bet is that some of the constructivists would argue that external reality is unknowable, that all meaning is constructed by the individual, and that coherence is what's important.

If you're looking for a dissertation topic, this may have potential.

danielmg April 5th, 2005 11:46 AM

Re: Is it important to change the client's dysfunctional cognitions?
I´m afraid it´s not OK the reference of the first article. I have found at
Beevers, Christopher G.1,2,4; Keitner, Gabor I.1,3; Ryan, Christine E.1,3; Miller, Ivan W.1,2. Cognitive Predictors of Symptom Return Following Depression Treatment. Journal of Abnormal Psychology 112(3) August 2003 p 488–496

Dieter Dvorak April 18th, 2005 03:43 PM

Re: Is it important to change the client's dysfunctional cognitions?
According to currently burgeoning "third wave approaches" such as Acceptance and Commitment Therapy (ACT) it might be more important to change the client's dysfunctional cognitions and responses to dysfunctional cognitions. Something, of course, which has been done implicitly, within CT of the traditional "Beckian" type, anyway. You cannot really do any thought record without "standing back" from your cognitions. A closer look at Haye's et al. work might be helpful in this debate ;) .

James Pretzer April 18th, 2005 09:15 PM

Changing dysfunctional cognitions vs changing the relationship to the cognitions
Good point. I like Hayes' idea that we need to help clients change their relationship to their dysfunctional thoughts and I agree that this has been implicit in Beckian CT. Perhaps if we look at it more explicitly we'll find more effective ways to doing this.

However, my understanding is that Hayes argues emphatically that we should not try to challenge the content of dysfunctional cognitions, just focus on changing their relationship to the cognitions. I must admit that I don't quite understand his reasoning on this point. Does anyony understand why he's convinced that we shouldn't try to change dysfunctional cognitions?

dieter (ClinPsych) December 7th, 2005 03:26 PM

Re: Is it important to change the client's dysfunctional cognitions?
My understanding of the ACT rationale is that even trying to change dysfunctional cognitions will dignify them in an undue way and reinforce "cognitive fusion" (i.e. taking thoughts/memories/images as literal truth). The whole thrust of ACT interventions is on undermining the client's "enmeshment" with his/her own thoughts and cognitive restructuring, therefore, is regarded as counterproductive.
Also, cognitive restructuring work, implicitly or explicitly, "colludes" with the client's control agenda (here: control of content of thought in order to control content/topography of emotional experience and associated behaviour) while ACT is focused on finding ways to "get on with life in a direction that is determined by the client's personal values" in the continued presence of aversive private experiences (i.e. thoughts, affect/mood, body sensations). In other words, in ACT the client's agenda of : "In order to lead the life I want to lead I will have to change my feelings/body sensations through changing my thoughts first" is sought to be replaced by the new agenda: "I will put my energy into actively trying to lead the life I want to lead while accepting that certain private experiences (cognitions,affect/mood/body sensations) may or may not be present.

In yet other words: Much like in DBT (opposite action principle) the idea is
1.that affect/mood/cognitive states will change if behaviour changes
2.the long-term satisfaction/dissatisfaction with life does depend more on one's actions than on cognitive content
3. trying to control private experiences (and cognitions in particular) is likely to produce paradoxical negative effects and leads to a rather maladaptive (ego-centric) fixation with these experiences at the expense of participating in one's actual life/context/environment
4. Therefore radical acceptance (achieved through building of mindfulness skills and cognitive defusion exercises rather than disputation and intellectual discussion) is more likely to produce a "fading" effect and flexibility in handling one's private experiences

In my personal practise I sometimes use cognitive restructuing techniques in order to "prime" mindfulness/acceptance work as it sometimes helps clients to just consider the possibility that their cognitions are not "made" of the same "stuff" as their actual/physical context.

(Sorry, that this reply took many months to be written)

James Pretzer December 12th, 2005 10:55 PM

Re: Is it important to change the client's dysfunctional cognitions?
I think ACT (and DBT) makes some good points and raises some important issues. However, I have some problems with the way in which the differences between CT and ACT are discussed by some ACTers. On several occasions when I've heard Steve Hayes speak, his comments have been framed as though (1) it is obvious that CT consists only of cognitive restructuring, (2) cognitive restructuring doesn't work, (3) therefore CT doesn't work and we should abandon it. In a recent (and very lively) debate on the Academy of Cognitive Therapy listserv, Steve made the point that we should draw a distinction between the principles of ACT and his presentation style. It may be that some of the apparent contradictions between ACT and CT are due to Steve's communication style rather than to inherent contradictions between the two approaches.

I'd argue that cognitive restructuring can reinforce cognitive fusion and collude with the client's control agenda, but that it need not do so. In fact, it seems to me that cognitive restructuring implicitly draws a distinction between the thinker and the thought and explicitly questions whether the client's thoughts/memories/images are "true". It may well be that "rational responses" may be contraindicated when the client is trying to use them to control internal experience. Certainly I wouldn't agree to an agenda of "In order to lead the life I want to lead I will have to change my feelings/body sensations through changing my thoughts first." At most, I might investigate whether helping the client change his or her thoughts is a useful way to help them achieve their goals.

If ACT's agenda is "I will put my energy into actively trying to lead the life I want to lead while accepting that certain private experiences (cognitions,affect/mood/body sensations) may or may not be present", then it has the same agenda that I have with most of my clients. I spend a lot of my time working to get clients to go ahead and do what makes sense despite aversive thoughts, feelings, or physical sensations. It's not that I've abandoned CT, it's that CT never said that humans should eliminate all unpleasant thoughts, feelings, or sensations and never said that one should control all internal experience by changing one's thoughts (or in any other way).

At the recent ABCT convention, Steve complained that CT is a "moving target" i.e. whenever he thinks that he has identified something unique about ACT, Cognitive therapists say "Oh, we do that too." Well, from what I've heard, it sounds as though Steve has had a very narrow view of CT and hasn't grasped the breadth of CT interventions. He's focused on radical acceptance more intensely than most of us have, but actually CT's been using acceptance-based interventions for a long time. He's emphasized values more than we have, but it's not as though values are something new that we never thought of before.

There may be some very useful things CT can learn from ACT but I doubt that we'll need to abandon CT.

alexandra_k January 12th, 2006 07:39 PM

Re: Is it important to change the client's dysfunctional cognitions?
Lol! What’s in a name? You can say that ‘cognitive therapy’ is in contrast to ‘behaviour therapy’ and then the behaviourists can talk about how distressing emotional responses can result from conditioning without cognition, and the cognitivists can cite studies where changing cognition results in a change in distressing emotional state. Or you can say that ‘cognitive behaviour therapy’ takes the insights from both. If you want to know what is distinctive about cognitive therapy (as opposed to other varieties of therapy) then I would have thought the focus on changing the clients cognitions was the most salient feature. And ACT’s focus on acceptance is what is distinctive about that. But in practice… Wise to be a little eclectic I would have thought.

The ‘disputation’ vs ‘socratic’ approach is interesting to me. I agree with JustBen’s point that terms are bandied about without their meanings being made clear. While we shouldn’t hold off using the terms until necessary and sufficient conditions are forthcoming it would help matters somewhat if people could gesture towards what they mean by those terms and also provide some concrete examples of differences in the approaches thus going someway towards operationalising them. I mean… Is it that ‘disputation’ tends to me met with resistence while ‘collaborative empiricism’ tends to result in the client being happily engaged? If this is the difference then I’m sure everyone would agree that ‘collaborative empiricism’ is preferable (and is ultimately likely to be more productive) than ‘disputation’. It is an interesting point that Socrates was made to drink Hemlock because people felt upset in response to his method of questioning…

How do you feel when I tell you that you have lots of irrational thoughts? How about maladaptive thoughts? How about thought distortions? Perhaps… It is the labelling of the clients thoughts as ‘irrational’, ‘maladaptive’, and / or ‘distorted’ that functions to get the client on the back foot resisting the therapists attempt to change them. Is it thought that you need to ‘unsettle’ the client before they will be prepared to work towards change?

The trouble with truth… Is you have to clarify what you mean by truth. Truth might be correspondence with reality, truth might be coherence with the clients web of beliefs, truth might be what is useful (pragmatic). The sad fact is that the rationality that people exhibit in general is far from ideal. All of us are prone to a variety of ‘irrational’, ‘maladaptive’, and / or ‘distorted’ thoughts. Yet not all of these thoughts are the focus of therapy (not should they be). Rather… It is a certain subset of the clients thoughts that are targeted by the therapist and these thoughts do not seem to be inherently more ‘irrational’, ‘maladaptive’, and / or ‘distorted’ than countless other thoughts that we exhibit in our daily lives that are not considered problematic. Hence… It would seem to me that cognitive resturucturing is less about ‘truth’ than it is about how unhelpful the therapist judges some of the clients thoughts to be. And perhaps the Socratic approach… Involves questioning so that the client can figure out for themselves what thoughts are unhelpful to them rather than being provided with a list of thoughts that the therapist has already decided are targets for change.

>… Hayes argues emphatically that we should not try to challenge the content of dysfunctional cognitions, just focus on changing their relationship to the cognitions.

I don’t think… We choose what thoughts will pop into our heads. If I direct you ‘don’t think about oranges’ then you will find yourself thinking about oranges in order to understand what I’m asking you to do (it is an ironic process). I wouldn’t have thought that cognitive restructuring would mean that those thoughts just don’t present in the clients conscious experience anymore. If anything, cognitive resturucturing might be more likely to have them recur to the client. What it seems to aim to do, however, is to reduce the ‘assent’ that the client feels when the thought occurs to them. We think a lot of things that we do not believe. At least… I do.

But my guess would be… It is coming up with the more helpful alternative thoughts… Alternative thoughts that the client may be able to bring themselves to believe that would be the most profitable. But judging the utility of thoughts / beliefs… Perhaps the thought is to emphasise that the client needs to be the judge of that...

Michael Vurek February 27th, 2006 04:01 AM

Re: Is it important to change the client's dysfunctional cognitions?
As a recent explorer of ACT and a long-time fairly traditional CBT therapist I follow this discussion with delight. I have always found mindfulness and acceptance practices in cognitive restructuring, and now I think I can still see cognitive restructuring in ACT. What is currently interesting to observe is my own shifting between guided exploration and broadening of a client's thoughts or beliefs, and guided practice of "acceptance technologies" depending on what's happening in the context of the session or course of treatment. From my CBT training I try to keep an eye on our collaborative conceptualization, and from recent undertandings of DBT and ACT I watch for my own experiential avoidances.

Please excuse the length of the following. It is an outline I recently did for myself in preparation for training in some basic CBT skills.

Doing thought records, in any of a variety of forms, facilitates and is facilitated by mindfulness. We can learn how to observe, describe and write down automatic thoughts, without judgment, and just noticing with curiosity how they are linked to states of mind.

For “facts that support the hot thought” I tend to use the language “what is true” or “what I need to accept”. The point is the same, I believe: to state in objective, factual terms what grains of truth reside in the hot thought. There is more opportunity to practice when we shift "emotional mind" thoughts back up to the automatic thoughts section. It can also be interesting to discern the difference between the emotions associated with these facts, and the ones associated with the hot thoughts - often sadness instead of hopelessness; disappointment instead of anger; etc.

For “facts that don’t support the hot thought” I tend to use the language “what else is true” or “what data lies outside the emotional mind view of the situation”. I emphasize that the practice is designed to “broaden” our view, not necessarily “correct” it. The balanced thought becomes what is true, and what is also true.

The thought record becomes another skill, built of several sub-skills, which the client can take or leave, once they have some sense of it.

Continuums are a parallel tool, giving clients the opportunity to validate the energy associated with the emotion and hot thought, which is the gap between how we want things to be and how they are. We also identify the more complex and variable nature of how things are when we look objectively, rather than via the absolute nature of hot thoughts or rigid beliefs associated with negative states of mind.

I enjoy the natural progression into action plans and experiments. Action plans speak to conditions and behaviors that are associated with the “true” side of thought records or continuums. When our actions or the conditions of our lives are inconsistent with our values, we seek to make changes. It helps to have structure to guide those changes, and a means for predicting the predictable problems that will arise in the process.

Experiments seem to emerge from balanced thoughts (that are logical/reasonable, but not credible) and identified values or aspirations. Values and aspirations emerge from lines of constructive Socratic questioning. Predictions are often about the pain that is naturally inherent in the new behavior – pain that may have been greatly intensified by years of “experiential avoidance”. Beliefs become mile-markers. We can observe how they shift, or gain/lose credibility, over the time of experimentation.

I’m exploring the clinical value of working with core beliefs and schemas. I know that I am interested and curious about them, and encouraging that curiosity can be helpful to clients. There are various “teaching points” regarding observable habits of mind, specifically its propensity to create short-cuts for understanding experiences. We can learn how these short-cuts are 1) conditioned by events and our response to those events; and 2) become “facts” that subsequently influence/distort future responses to unique and new experiences. There is also the very moving experience of clients contacting their schemas with kindness and compassion. It seems to evoke a rich sadness, and may lead to extending kind and compassionate curiosity about other contents and habits of mind.

James Pretzer April 4th, 2011 12:57 PM

Despite theoretical debates, sometimes cognitive changes have major benefits
A recently-published study examined the role of cognitive change (change in catastrophic misinterpretations of bodily sensations) in the treatment of panic disorder. Participants were 43 adults diagnosed with panic disorder who received 12 weeks of panic control treatment (a CBT approach developed by Barlow and colleagues). Researchers assessed panic disorder severity weekly and assessed catastrophic misinterpretations, agoraphobia, and peak anxiety prior to sessions 1, 3, 6, 9, and 12. They found that change in catastrophic misinterpretations was associated with later reduction in overall symptom severity, frequency of panic attacks, distress and apprehension, and avoidance. The researchers note that their results showed better outcomes when cognitive change preceded symptomatic improvement.

This, of course does not suggest that a purely cognitive approach to treating panic disorder would be a good idea. First, behavioral experiments can be an important part of achieving cognitive change. Second, if you achieve cognitive change and don't follow up with in-vivo exposure to avoided situations and avoided sensations, you aren't likely to achieve lasting improvement. However, it does provide fairly clear evidence that achieving cognitive change can be an important part of effective treatment.
Teachman, B. A., Marker, C. D., & Clerker, E. M. (2010) Catastrophic misinterpretations as a predictor of symptomatic change during treatment for panic disorder. Journal of Clinical and Consulting Psychology, 78, 964-973.

Fionnula MacLiam May 22nd, 2011 04:40 AM

Re: Is it important to change the client's dysfunctional cognitions?
I'm surprised that Longmore & Worrell's paper hasn't come up in this discussion:

Longmore & Worrell, 2007, Do we need to challenge thoughts in CBT?, Clinical Psychology Review, 27, 173-187

available at

(Although, I thought Behavioural Experiments are specifically designed to test thoughts & beliefs, as they don't generally fulfill criteria for exposure.)

James Pretzer June 9th, 2011 01:35 PM

Re: Is it important to change the client's dysfunctional cognitions?
The Longmore & Worrell (2007) article is a good one. Thanks for calling it to our attention. I'd encourage anyone interested in this topic to take a look at it. I'd also encourage them to think for themselves when considering the conclusions that Longmore and Worrell draw.

Both the title of the article and the opening line of their Conclusion focus on the question "do we need to challenge thoughts in CBT?" and specifically, do we need to use "logical, rationalist methods" to challenge dysfunctional thoughts and beliefs? This is a legitimate question to ask, but does anyone argue that CBT must must challenge dysfunctional thoughts or that we must use "logico-rational" strategies in doing so?

I can think of quite a few authors who argue that it is useful for therapists to directly challenge dysfunctional thoughts and beliefs and who argue that the strategies that Longmore & Worrell categorize as "logico-rational" can be a useful way of doing so but I can't think of anyone who argues that use of these strategies is necessary for CBT to be effective or that use of these strategies is sufficient for CBT to be effective.

This is an important point. Quite a few studies (many of which are summarized by Longmore and Worrell) show that behavioral interventions, cognitive interventions, and a combination of cognitive and behavioral interventions are equally effective in treating a number of different problems. If anyone was saying that cognitive interventions are more effective that behavioral interventions or if anyone was saying that cognitive interventions are necessary for treatment to be effective, the data would show that they are wrong. However, I'm not aware of anyone who takes that position.

CBT is distinguished by a variety of intervention techniques for altering dysfunctional cognitions. Some of these techniques rely on logical analysis (such as examining the evidence for and against a thought or identifying cognitive distortions) and some of them are behavioral in nature (such as behavioral experiments or in-vivo exposure). CBT also uses many interventions that are shared by other therapeutic approaches. Many who have criticized CBT talk as though we assume that "logico-rational" interventions are necessary and/or sufficient for treatment to be effective. However, that is not our view. We argue that specific "logico-rational" interventions often are useful, but that is quite different from arguing that they are necessary, sufficient, or superior to other interventions.

Cognitive Therapy's stance is that with most problems we need to use both cognitive and behavioral interventions. With moderate to severe depression we advocate using behavioral interventions first (increasing activity and involvement in potentially reinforcing activities), then using a combination of "logico-rational" and behavioral interventions to modify dysfunctional cognitions and dysfunctional interpersonal behavior. With phobias, we advocate addressing fears cognitively, through teaching skills for coping with anxiety, and through in-vivo exposure. The same applies with many other problems. The available research shows that cognitive interventions are no more and no less effective than behavioral interventions. Some of the art in CBT lies in choosing which interventions to use with a given client as well as when and how to use them.

Do we need to challenge thoughts in cognitive behavior therapy? No, we don't need to. However, the empirical evidence shows that, in general, cognitive and behavioral interventions are equally effective with a number of problems and clinical experience shows that cognitive and behavioral interventions work well together.
Longmore, R. J. & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy?, Clinical Psychology Review, 27, pp.173-187.

James Pretzer July 26th, 2011 10:04 AM

Do rational responses and behavioral experiements have different effects?
It has been argued that different CBT interventions operate through different mechanisms of change. For example:

Bennet-Levy, J. (2003). Mechanisms of change in cognitive therapy: The case of automatic thought records and behavioural experiments, Behavioural and Cognitive Psychotherapy, 2003, 31, 261

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