Becks Cognitive Therapy

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therapists (e.g., Clark, 1986; Teasdale, 1983, 1999) have argued for a circular relationship between cognition and emotion rather than a simple linear one; we will examine Clark's approach to panic in more detail in the next section and in Chapter 6.

There are two main components to the theory from which the general therapeutic approach is derived (see Figure 4.3). The first of these focuses on the types of cognitive structures that underlie the emotional disorders and the second focuses on the types of cognitive processes that are involved in the onset and maintenance of these disorders.

The type of knowledge representation that cognitive therapy focuses on is schemas. These structures have been widely used (and abused) in the history of twentieth-century psychology and have appeared in the work of Bartlett and Piaget and in modern cognitive psychology. In Beck's use of the term, schemas are seen to be the units by which memory, thinking, and perception are organised; they have been considered by most writers on cognitive-behaviour therapy to be no more than collections of (propositional) beliefs. To quote:

Cognitive structures or schemata . . . are relatively enduring characteristics of a person's cognitive organization. They are organized representations of prior experience . . . A schema allows a person to screen, code, and assess the full range of internal or external stimuli and to decide on a subsequent course of action . . . schemata encompass systems for classifying stimuli that range from simple perceptual configurations to complex stepwise reasoning processes. (Kovacs & Beck, 1978, p. 526)

These schemas are in part derived from past experience, such as from the child's relationship with its parents, but they are not seen to be passive representations of that experience. Instead, they go beyond the current information; activation of part of the schema leads to activation of the whole schema, therefore information not

EARLY EXPERIENCE (e.g., criticism and rejection from parents)

FORMULATION OF DYSFUNCTIONAL ASSUMPTIONS (e.g., unless I am loved I am worthless)

CRITICAL INCIDENTS

ACTIVATION OF ASSUMPTION

NEGATIVE AUTOMATIC THOUGHTS

DEPRESSION

Figure 4.3 Beck's model of depression.

represented in the input will be filled in according to the operative "default" values. To give a simple example, if you were shown part of a picture or description of a house, a "house schema" would be activated which would include certain "default" features such as windows, doors, a chimney, walls, and so on, even though these were not explicitly presented in the original description. The argument is therefore that schemas that relate to interpersonal relationships and important roles and goals may also be activated in a similar manner. The patterning of self-schemas and significant-other schemas, which is based on past experience, will provide the starting point from which current relationships and experiences are viewed.

In relation to specific emotional disorders, Beck has argued that certain groups of dysfunctional schemas are likely to be characteristic. For example, in relation to depression Beck (e.g., Beck, Rush, Shaw, & Emery, 1979) has proposed that these schemas reflect in part a so-called "cognitive triad" that focuses on negative views of the self, of the world, and of the future. That is, the depressed individual is likely to see the self as failed, diseased, or worthless, the world to be full of destructiveness and poverty, and the future to be bleak and hopeless. However, Haaga, Dyck, and Ernst (1991) have pointed out that the cognitive triad really focuses on the self in relation to the negative aspects of the world and the future, rather than the world and the future more generally. Haaga et al. (1991) and Clark and Beck (1999) have summarised the empirical evidence that shows at least some support for the proposed triad, although it may be sufficient for part rather than all of the triad to be present for depression to occur. Beck (1983) has further suggested that depression-prone individuals may be divided into two types; so-called "sociotropic" individuals whose dysfunctional beliefs are centred on issues of dependency on others, in contrast to "autonomous" individuals who are highly goal-oriented and who distance themselves from others. Similar distinctions have been made by Arieti and Bemporad (1978) and Blatt and his colleagues (e.g., Blatt, D'Affliti, & Quinlan, 1976). The data that test the usefulness of the sociotropy-autonomy distinction has so far been mixed (Clark & Beck, 1999; Weishaar, 1993) with more support for the role of sociotropy than autonomy (Hammen, 2005). One problem is that the self-report scale designed to assess the distinction, the Sociotropy-Autonomy Scale (Beck, Epstein, & Harrison, 1983), may be more at fault than the distinction itself.

In between episodes of emotional disorders such as depression or anxiety, Beck has proposed that dysfunctional schemas are inactive and lie dormant; they become activated only when appropriate matching stressors occur (see Figure 4.3 above). Part of the reason for this proposed latency of dysfunctional schemas has been to immunise the theory against the failure to find elevated levels of dysfunctional attitudes and automatic thoughts during recovery. That is, the theory might well have predicted that dysfunctional schemas were active even between episodes of depression and anxiety, but unfortunately the initial empirical research suggested otherwise (e.g., Power, 1990). However, it seems unlikely that such important concerns for the individual become inactive: that, when well, the individual is no longer concerned with issues about failure and rejection, about success, love, and admiration. One alternative possibility is that the dysfunctional schemas remain active but that during recovery the individual is able to inhibit the outcomes of such processing. We have also argued that it may be a mistake to focus on global dysfunctionality in assessment and have presented preliminary evidence that at least some core dysfunctional schemas, especially those centred on dependency issues, may remain elevated even during full recovery from depression (Lam, Green, Power, & Checkley, 1996; Power, Duggan, Lee, & Murray, 1995). A second possibility is that the traditional view of schemas that is incorporated into cognitive therapy is too simplistic to capture the type of high-level representation system necessary within cognition-emotion systems. Teasdale and Barnard (1993; Teasdale, 1999) have argued that a hybrid representation system called "schematic models" provides the dynamic complexity that means that core schemas do not have to be considered "latent" between episodes of depression; we will return to this possibility later in this chapter and in Chapter 5.

The second main component of Beck's cognitive therapy focuses on cognitive processes. The effect of the activation of dysfunctional schemas is that they produce negative automatic thoughts of the form "I'm a failure" or "I'm unlovable" which the individual believes. Unlike healthy individuals who can dismiss such thoughts, the depression-prone individual may indeed seek further evidence in support of these negative thoughts and beliefs. This evidence seeking includes the so-called logical distortions of thinking that Beck has outlined; these distortions include magnification (e.g., of negative material related to the self), minimisation (e.g., of positive material related to the self), and personalisation (e.g., taking the blame for anything negative). The outcome of these distorted processes, in combination with other biases such as for memory, is that the depressed individual maintains a negative view of the self and thereby remains depressed (see Chapter 7).

Two main points that we would raise about this view of cognitive processes are first that, at least in its original form, the approach implies that normal thinking is logical and rational, and second that it presents a view of the self-concept in depression that is monolithic and negative. To take the first point, whether or not normal thinking is logical and rational (indeed, whether it can ever be truly logical and rational) is a question that remains unresolved (e.g., Evans, 1989); thus, there are numerous demonstrations of the range and types of distortions that affect normal thinking. In one such classic demonstration, Wason and Johnson-Laird (1968) presented participants with the sequence "2 4 6 ..." and asked them to work out what the underlying rule was. Most people set about confirming that the rule was "numbers increasing by two" through the production of additional examples that followed this rule; only after many failed attempts did some appreciate that examples which would falsify their hypotheses rather than confirm them were far more informative. The correct rule "numbers increasing in size" was guessed by very few of the participants. Oakhill and Johnson-Laird (1985) present examples that are even more relevant to Beck's proposals in a series of studies in which they showed how prior beliefs interfere with the process of reasoning in normal participants. They found that erroneous conclusions were more likely to be accepted in a reasoning task if the conclusions agreed with prior beliefs or knowledge (e.g., "some women are not mothers") than if the erroneous conclusions disagreed with prior beliefs or knowledge (e.g., "some athletes are not healthy"). Examples such as these illustrate how normal thinking and reasoning reveal many of the distortions that Beck originally attributed to depressed individuals. We propose, therefore, that the differences between normal and depressive thinking may be less that of logical versus illogical thinking and more that of positively biased versus negatively biased processes. We have further suggested that the so-called findings of "depressive realism" (Alloy & Abramson, 1979), in which, contrary to Beck, it was argued that depressed individuals are more rather than less realistic when compared to normal individuals, may be due to the fact that depressed individuals find negatives more congenial as conclusions in thinking and reasoning tasks, therefore they will appear more realistic when the negatives are true, but less realistic when the negatives are false (see Chapter 7). That is, we suggest that the issue has been incorrectly presented as one of realism or logic, when it should more correctly be considered one of the acceptance of conclusions that are congenial to the current dominant model of the self (Power & Wykes, 1996). This shift in emphasis does, however, appear to be reflected in Beck's more recent work (see Clark & Beck, 1999; Weishaar, 1993).

The second point raised about Beck's view of cognitive processes was that it leaves the impression that the self-concept is "monolithically" negative in depressed individuals and "monolithically" positive in normal individuals (Power, de Jong, & Lloyd, 2002). One puzzle, therefore, to which cognitive therapy fails to provide an adequate answer is how the self-concept switches from being negative during an episode of depression to being positive during recovery. If, for example, the proposal is that the negative self-schemas are latent between episodes and only activated during an episode of depression, we must ask what happens to the positive schemas that are active between episodes. Are they de-activated in some way during an episode of depression or do they remain active? If the positive schemas remain activated, then the depressive self-concept should demonstrate both positive and negative elements; that is, the depressed individual should show self-ambivalence rather than straightforward negativity. In fact, a number of studies provide supporting evidence for this proposal. Brewin, Smith, Power, and Furuham (1992) found that although clinically depressed individuals described themselves in primarily negative terms when asked to describe themselves "right now", they used terms that were equally positive and negative when asked to describe themselves "in general". Wycherley (1995) reported a similar effect when the terms were manipulated from being more global to being more specific; that is, although clinically depressed individuals were largely negative when the terms were global descriptors (e.g., "my life is a failure"), they became more positive the more specific the item (e.g., "I'm a failure in my work"). Finally, in an emotion-priming task, Power, Cameron, and Dalgleish (1996) found that positive phrases primed an increase in positivity in clinically depressed individuals, in addition to the expected priming effects of negative phrases. When taken together, studies such as these suggest that a more sophisticated view of the self-concept needs to be incorporated into our views about the emotional disorders. Consequently, more recent analyses of the nature and inter-relationship of schemas in depression have addressed these questions (e.g., Elliott & Lassen, 1997) and we will return to this point later in this and subsequent chapters.

Before we turn to consider some of the more recent applications of cognitive therapy, it should of course be noted that the great strength of the approach rests on its practical use as a therapy for an increasing range of emotional disorders, whatever limitations one might wish to highlight in the underlying cognitive theory. Because the details of the therapy are beyond the scope of the present account, the interested reader is referred to the many accessible accounts of the practice of cognitive therapy (e.g., Beck & Emery, 1985; Beck et al., 1979; Williams, 1992) and useful summaries of the outcome studies designed to assess the effectiveness of the therapy (e.g., Roth &

Fonagy, 2005). However, as noted previously (e.g., Power, 2002; Power & Champion, 1986) evidence of the effectiveness of the therapy is not proof of the correctness of the theory. Witness the various ancient theories such as the doctrine of the four humours and their associated therapies such as blood-letting and trepanning; these treatments undoubtedly helped enough individuals in order to maintain the practices over some thousands of years, although we now know that the underlying theories were somewhat awry.

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