What uncertainties do we face in CT/CBT?

[Doug William]

Hi James---

Is it possible that the process is so hard because we don't really understand any of the most basic biological processes that underlies thought, affect, motivation and on and on. That possibly the automaticity of thought and affect are so interwined that they cannot really be separated, other than our proclivity to do so---- and that maybe when you try to change a system (the way the brain actually works) before you really understand it, that there is, by necessity, a lot of dancing in the dark?

I would enjoy a discussion that speaks about the uncertainities of cogntive therapists and what are the most pressing unanswered questions that cogntive therapists might have. And please understand I would ask exactly the same thing of any forum on this site. And believe me when I say, I have no allegiance to any particular theory or way of thinking. I am only asking if a certain kind of discussion is possible here.

What don't cogntive therapists understand yet that you think is crucial to understand about doing cogntive therapy with our patients/ clients.

Where do your uncertainities exist? Are we allowed to talk about such things?

Thanks,

Doug

[James Pretzer]

We certainly face plenty of uncertainties when we move from reading the texts to applying CT either in clinical practice or in real-life research. It is much simpler to discuss the concepts than it is to test the theories or to make lasting changes in people's lives.

One area that is still full of uncertainty is the interface between biology and cognition. Another area of uncertainty is the exact relationship between affect and cognition (does cognition preceed emotion, does emotion preceed cognition, are they two partially independent sub-systems, ...). There's quite a bit of uncertainty about the mechanisms through which CT works (therapeutic realtionship vs specific techniques vs ...). Currently, I'm giving a fair amount of thought to another area of uncertainty, CT's approach to dealing with topics such as transference, the unconscious, and childhood trauma that traditionally have been the province of psychoanalysis (see http://www.cape.org/2005/pretzer.html).

There are also plenty of clinical problems where we're debating which treatment protocols are most promising and how to deliver them most effectively. Even with topics as basic as CT of depression, some are arguing that "behavioral activation" is as effective as the full CT protocol and that there is no need to do Beckian CT.

There is no danger of running out of topics to research and debate in the forseeable future.

While there is plenty of uncertainty and much is left to be figured out, I'm not sure that any of this is crucial for effective treatment. I'd argue that we have good evidence that CT works well for quite a few problems. Our uncertainty lies largely in understanding the exact mechanisms through which it works, figuring out how it can be improved, figuring out how to apply it effectively with a broader range of people and problems, and figuring out how to make it available to more of the people who need effective treatment for serious problems.

Yes, certainly the uncertainties we face are a very worthwhile topic for discussion. Which uncertainties shall we talk about?

[JustBen]

It's interesting that you mention the relationship between affect and cognition -- I was thinking about posting a question on that very topic. When I was first learning the basics of CT, I started with some books written for the general public. Uniformly, they presented a straightforward "thoughts precede emotions" standpoint, and when I moved on to "Cognitive Therapy: Basics and Beyond" by Judith Beck, this view was reinforced.

As I started reading casebooks and journals, however, I started finding statements like, "Of course, it's nieve to still believe that cognition always precedes emotion. The relationship between thought, affect, and behavior is complex." Somehow, though, the author never goes into more detail about this relationship.

I have three questions:

1. What is the "mainstream" view on this? Do most cognitive therapists still hold to the "thought precedes emotion" formula, or have they embraced the more "complex" view?

2. Where is the "missing link" between these two viewpoints? Earlier works seem to hold to the old formula, and newer works seem to make the case for the "complex relationship" as if it's a well-established viewpoint, but where and when did this new viewpoint emerge? (I can't seem to find it in the literature. Admittedly, my resources are kind of slim.)

3. If one believes that emotion precedes thought, then what possible benefit could be derived by challenging cognitive distortions and developing adaptive responses? Are we conceptualizing some kind of feedback loop?

[Palamino]

I recommend you look at Gordon Bowers Associative Network Model, this describes an interconnected system of feelings thoughts and behaviors. It is just another way of looking at how emotional networks can drive info processing, but cognitive behavioral therapy adresses this by targeting the cognitions and or behaviors.

Branded

[James Pretzer]

1. The straightforward "thought preceeds emotion" model is a common misunderstanding or oversimplification of CT's view. What Beck really says is that the brain is constantly and automatically appraising perceived stimuli. These appraisals (aka "automatic thoughts") elicit emotional and behavioral responses. However, the chain of events doesn't stop at that point. The individual's mood biases cognition in mood-congruent ways. This tends to result in additional mood-congruent thoughts which elicit additional emotional and behavioral responses, ... ad infinitum.
   
   A good example is Beck's discussion of "the downward spiral of depression." Negative automatic thoughts tend to elicit a depressed mood, a depressed mood tends to bias perception and recall in a way that results in vigilance for negative experiences, enhanced recall of prior negative experiences, and a more pessimistic outlook. This tends to result in additional negative thoughts, which tend to elicit more of a depressed mood, ...
   
   
2. Beck has endorsed a more complex view than "thoughts cause feelings" at least since the early 1970's if not longer. However,some authors have misunderstood his view and some have presented the model more simplistically when writing for non-professional audiences.
   
   Debate over whether cognition always preceeds emotion heated up when Zajonc published a major article in the early 1980's that seemed to provide empirical evidence that emotional responses occurred before cognitive responses did and some interpreted this as contradicting CT. Actually, Zajonc's research didn't show that emotional responses preceed cognitive responses, it showed that simple appraisals such as good/bad or threat/non-threat can occur before a stimulus is fully perceived and can elicit emotional responses. This is an interesting finding but is doesn't contradict CT. I'm not aware of any solid evidence that emotion precedes appraisal in clinically-relevant situations.
   
   
3. If emotion really did preceed thought, this would present a variety of conceptual problems such as "If emotion preceeds recognition and appraisal of the stimulus, then what determines the emotional response?" However, even then I'd argue that we have good evidence that cognitive interventions are useful with a variety of serious problems (especially when used in the context of a good therapeutic relationship and accompanied by experiential and behavioral interventions).

...

One of the shortcomings of current CT accounts of the relationship between cognition and emotion is that we tend to talk as though automatic thoughts happen in isolation, one at a time, followed by emotional responses, one at a time. In reality, a constant stream of automatic thoughts is accompanied by a constant stream of emotions, each influencing the other. We tend to talk as though it is simply a matter of thoughts causing feelings because this simplified view is easier to put into words and works well enough to lead to clinically useful interventions, not because it is a comprehensive model of the relationship between thoughts and feelings.

[Micah Perkins]

I firmly believe in (CBT and REBT). This belief is based upon my reading of the research and my own personal and professional experience. Even though I do believe that it is important for clients to identify and discuss their feelings,. real change (lasting change) occures when they change their thinking and actions (even though they still may not feel like it). How many times have I heard someone say 'I talked and talked and talked about it, but it was only after I realized ________ and did something about it did my life get better.'
Even though I firmly believe in CBT and REBT, they, like all psychotherapies have their limitations. The limitation may be in the theory itself , the particular client, or in the practioner using the theory. To me, there still remains a big void in how to use CBT with families (if anyone has any good books to refer me to, let me know). I think that it is important to use CBT/ REBT as a framework, but to be willing to use techniques from other theories if it is more helpful to the particular client. If leading the client to directly evaluate their thinking is not working, then we have to find other ways to help them change their thinking and actions.
Maybe someday we will find a much better way of helping others, until then, I think this is the best way.

[James Pretzer]

I have an update! Dr. Beck and I are currently updating his chapter on CT's approach to stress and stress management for the third edition of Lehrer & Woolfolk's book on stress management. This morning I updated the discussion of the relationships between cognition, emotion, and behavior. The model Beck advocates is basically:

1. An event happens.
2. Schemas shape perception and appraisal of the event.
3. The "primary appraisal" is very quick (before the stimulus is fully perceived), automatic, very simple (i.e. good/bad, dangerous/not dangerous, etc.), and occurs outside of awareness.
4. The primary appraisal elicits both the initial behavioral inclinations (fight or flight...) and the initial emotional responses. Behavioral inclinations and emotional responses are seen as being independent of each other but as being correlated because they are both elicited by the same appraisals.
5. Secondary appraisals automatically follow the primary appraisal and provide a somewhat more sophisticated assessment of the risk or gain that the situation presents and of the individual's ability to cope with the situation. This is still a simple, quick appraisal that occurs automatically and is likely to occur outside of awareness.
6. The secondary appraisals fine-tune or modify the initial behavioral and emotional response to the situation.
7. The initial appraisals and resultant behavioral and emotional responses influence how the situation unfolds. In other words, the initial behavioral response (i.e.fight or flight or freezing) makes a big difference in what actually occurs and the initial emotional response makes a big difference in how subsequent events are appraised (if I'm scared I'm more likely to interpret whatever happens as a threat, if I'm angry I'm more likely to interpret it as a provocation.
8. Subsequent thought can modify or reinforce the initial appraisals, inhibit or facilitate the behavioral inclinations, and/or lead the individual to suppress or express the emotional responses. Dysfunctional beliefs, cognitive distortions, etc. contribute to dysfunctional responses.
9. This is not a static process with a beginning and an end. We are constantly and automatically appraising events (both external and internal) as they occur whether or not we are aware of the appraisals and their effects. Our behavioral and emotional responses to prior appraisals influence subsequenct appraisals.

Clearly this is a little more complex than "thoughts cause feelings." Note that reflective, verbally-mediated thoughts of which the individual is aware come into the picture relatively late in the chain of cognitive processes.

[Doug William]

Hello again James---

Thank you for your initial reply to my post and the richness of presentation you offer. I had hoped that much more discussion would be prompted in the month I've waited to reply, but obviously that's not going to happen. I've also waited this long in trying to sort out the dizzying number of issues that you've raised!!! This is my third draft of a reply, because I really can't decide how to best focus my comments!! So I've decided to go much more slowly.

When you mention the interface of biology and cognition, I consider that cognition is biology, the two cannot be separated, but that's exactly the whole problem. We can keep 'saying' cognition this, affect that-- but it 'is' biology, not separate from it. We try the best we can to believe this is 'separate' from that but it isn't. It is our efforts to keep teasing things apart, or make chapter headings out of our psyche that leads us astray so much. It's a great teaching tool, but a real conceptual problem too. And in our 'verbal' arguments and verbal reasoning to make sense of it all, we, I think end up in a self-delusional mess. Affects, emotion, language development, memory, perception, learning, motivation, conscious thought, consciousness etc., each of these 'academic' areas in their own right yield tons of new questions and each specialist in each area go their own way We 'think' when we give any one these areas primacy and develop theories around them that we are progressing. I'm not so sure. And I'm not sure that the manner of research we use, clarifies as much as we think. Any historian of psychoanalysis or the behavior therapies (beginning with classical or operant treatments) and lots of other therapies where earnest efforts at research were made have revealed similar and somewhat amusing trends. First there is glowing optimism, and signs of high rates of success appear in the journals, disciples proliferate, as do training institutions. Then efforts are directed to make the theory and methods more and more inclusive, and more and more ideas are drawn in so the theorizing becomes more inclusive as well.

Then over time there is a dimming of enthusiasm and new ideas take over. Not progress mind you, but new ideas, new proliferations.

All that aside for a moment (not to mention all the other questions you've raised!!!), is it not important to consider that developmentally 'affect' came first. That has to hold some weight, doesn't it?? Our biological equipment introduces "affect" way before conscious language emerges. Unless one believes that conscious cognition develops apart from affect, we have to slow down here, don't we? And again, and I'm not espousing any particular theory here, how you can tease apart affect and cognition . I don't think you can. Of course, 'defining affect' is maybe the first important task. I'll stop here.

Thanks for the opportunity!

-Doug

[Palamino]

Read Gordon Bower, particularly his associative network model.....it is so clear and includes the important role of cognition and behavior.