Cognitive Therapy and the Emotional Disorders Book

Classic work on cognitive therapy by one of its founders. Parts are technical, but overall it's straightforward, easy to read, and a good introduction.

The basic idea of cognitive therapy (CT) is that a lot of anxiety is caused by thoughts. Typically, these are negative, irrational, automatic thoughts which go on at a low level of consciousness - not unconsciousness, but a sort of background chatter which you may not be aware of, but can easily call into awareness if you pay attention. Stuff like, "She hates me," "I'm a loser," "They won't hire me," etc.

These thoughts are what cause or precipitate anxiety, depression, and panic attacks; if you become aware of the thoughts, then you can challenge them and teach yourself to think them less. You will then be less depressed, anxious, and panicky. (Mindfulness-based CT suggests that all CT works not by literally changing your thoughts, but by changing your relationship to your thoughts. I think both are a factor, but I'm with the mindfulness camp that the relationship aspect is more significant.)

That's the basic theory. I'll highlight details I thought were especially interesting.

- Trust your client. If you ask them what they were thinking before the anxiety attack, you may have to make them dig a little, but eventually they'll come up with something. Trust what they give you. They know what they thought. Also ask for visual images and fantasies.

- Look for personal meanings. The public meaning of "hospital" is "place where people go to be cured." Your hospital-phobic client may have the personal meaning of hospital be "place where people are anesthetized, cut up, and die."

- This relates to root-cause beliefs. The negative thought might be "They don't like me." Asking why it's important to be liked may eventually elicit something like, "I must be liked by everyone always, or I'm worthless," or "I should be so wonderful that everyone loves me." (Shoulds are generally harmful and unrealistic. Listen for them.)

- Depressed/anxious people often think everything relates to them: if someone glances their way, it proves the person hates, scorns, or is laughing at them. They will gain in self-esteem once they consciously consider that they are not the center of the universe. (The single most important insight I got from doing CT, by the way. It sounds obvious but in real life, it's very easy to forget.) This can be subtle: you hear about someone having a heart attack and think, "That could happen to me." Sure, it could. But in reality, that's someone else's heart, not yours.

- Explain how CT works in advance. You are collaborating with your client; don't rigidly stick to your own agenda. Check in periodically to make sure you're on the same page; ask them if they disagree, and make sure they believe that disagreement is fine. Ask them to state areas of agreement and disagreement. Also, don't set yourself up as Superman who's going to swoop in and solve all your client's problems. They need to know that this is a partnership and they have to put in some serious work.

- Cognitive distortions are one thing, but you can't reason people out of actual delusions. However, you can sometimes get clients to stop acting on delusions by discussing the consequences of their behavior with them. (ie, they may still think their neighbor is the Devil, but be convinced that it would not be in their best interest to break his windows.)

- When clients come in with multiple problems, try to find a common theme, then tackle the theme. Similarly, try to see if there's a single problem which is causing all the others, then tackle that. (ie, multiple problems caused by root "fear of social interaction.")

- You don't need to solve ALL the problems. Once the major crises are resolved and the client has a handle on CT techniques and can use them on their own, they're good to go. Other stuff will come up, but the important thing is that now they're equipped to handle it.

- Experimentation: teach clients to figure out what their negative thoughts are (if it's not obvious) by recording thoughts before and during moments of anxiety/depression. Journaling is good for this. Eventually, patterns will emerge. Once the thoughts have been moved to conscious awareness, you can discuss whether or not they're valid. Simply learning to observe one's own thoughts often creates distance, which lessens the emotional impact. (This is the core of the mindfulness-based approach.)

- If they don't see how thoughts are unrealistic in conversation or if it's not sinking in emotionally, they can test their thought-hypotheses via real-world experimentation. (Is it really true that going to the party will be the worst experience ever?)

- Discuss the worst that can happen. Some negative thoughts do involve real possibilities. But in depressed people, the worst outcome is assumed to definitely happen, and goes way beyond bad stuff that could realistically happen. You want people to think, "My speech might be awesome, or average. But if it's terrible, the worst that will happen is I'll be embarrassed for a few days and that will suck, but it's unlikely to affect my job and my husband will be very sympathetic," rather than, "My speech will definitely be terrible, and I'll get fired, and everyone will scorn me, and I will be humiliated forever."

- Cognitive-behavioral interventions for depression: schedule activities. Have client rate activities for feelings of pleasure and mastery (accomplishment.) Consider alternative explanations and alternative actions. Cognitive rehearsal (imagine yourself doing stuff successfully.) Homework: experiments, log of automatic thoughts.