Changing Behavior, Changing Thinking
Building a Better You
In This Chapter
Learning better behaviors
Combing two approaches
Being mindful and accepting yourself
Balancing behavioral, cognitive, and mindfulness approaches
There are few things in life that I hate more than shopping for a car. If I’m looking for a blue two-door, compact pickup, the salespeople show me a white four-door model. If I want a sports car with front-wheel drive, they show me the latest, greatest, four-wheel-drive sports utility vehicle. I walk onto the lot thinking I know what I want, but somehow I leave thinking that I want something different.
Now imagine a similar experience in the context of going to a therapist. Mr. Ramirez is having marital problems, and one of his children is acting up at school. He knows that he wants help with his marriage and his child. But, when Mr. Ramirez meets with the therapist, something strange happens. He wants to talk about his marriage, and the therapist wants to talk about his childhood. He wants to talk about his kid, and the therapist wants to talk about his dreams. This guy may walk away from the encounter with “car-shopping disorientation disorder,” not knowing which way is up and what he really came to therapy for.
Jay Haley criticized therapy approaches that seem to ignore a patient’s real concerns and insist that her real problem is something else that’s related to some underlying or hidden issue waiting to be uncovered and analyzed. Psychoanalysts, for example, may be criticized as seeing the unconscious as the cause of any problem, even if it’s fear of flying. “The power of the airplane and your fear of flying represent your father and an unresolved Oedipal complex.” Say what? Do I really need seven years of psychoanalytic therapy to get over my fear of flying? I’d rather take the bus.
This chapter introduces two general classes of therapy that can probably pass the “Haley test.” Behavior therapy and cognitive therapy and combined iterations of the two are very widely used forms of therapy that have a simpler (but not simplistic) view of psychological problems. Behavior therapy focuses on behavior. Pretty simple, huh? So, if Mr. Ramirez went to a behavior therapist, the focus would be on the behaviors occurring within his marriage. Cognitive therapy focuses on thoughts, so a cognitive therapist would focus on the thoughts that Mr. Ramirez is having about his marriage and his kid. These approaches take a simpler and less mysterious approach to patients’ difficulties than psychoanalysis, for example.
Weeding Out Bad Behavior with Behavior Therapy
Behavior therapy emphasizes the current conditions that maintain a behavior, the conditions that keep it going. This form of therapy focuses on the problem, not on the person. A psychology professor who I once had, Elizabeth Klonoff, likened behavior therapy to a weed-pulling process. She stated that psychoanalysts attempt to pull the weed up by its roots so that it’ll never come back, but behavior therapists pluck the weed from the top, and if it grows back, they pluck it again. Of course, this makes behavior therapy sound more inefficient than it actually is. The idea is that in behavior therapy the developmental or childhood origins of a problem are not necessarily as important as the conditions that keep it going. In that sense, if you change the maintaining conditions of a behavior, then you have in essence “uprooted it,” as long as those conditions don’t recur. For example, who cares how you started smoking? The important part is the factors that keep you smoking.
Basing therapy on learning theories
All behavior is learned, whether it’s healthy or abnormal. Behavior therapy is based on the learning theories of Ivan Pavlov’s classical conditioning, B. F. Skinner’s operant conditioning, and Albert Bandura’s social learning theory. Here’s how these theories understand learning (see Chapter 9 for details):
In the classical-conditioning sense, learning refers to associations formed between events or actions.
In the operant-conditioning sense, learning refers to the process of increasing the likelihood of a behavior occurring or not occurring based on its consequences.
In the social learning theory sense, learning refers to discovering things by watching other people.
These days, it’s pretty hard to argue that smoking is not bad for a person’s health. I think most people now accept the unhealthy aspects of smoking as fact, but some just choose to ignore this information. Smoking is a good example of an unhealthy behavior that is learned. Cigarette advertisements associate sexy people and having fun with smoking (classical conditioning). Nicotine gives a pleasurable, stimulating sensation (operant conditioning). Teenagers sometimes learn to smoke by watching their parents, older siblings, or peers smoke (social leaning theory).
Classical conditioning and behavior therapy
Behavior therapy treats abnormal behavior as learned behavior, and anything that’s been learned can be unlearned — theoretically anyway (see Chapter 13 for info on abnormal behavior). A key feature of behavior therapy is the notion that environmental conditions and circumstances can be explored and manipulated to change a person’s behavior without having to dig around their mind or psyche and evoke psychological or mental explanations for their issues.
A classic case cited by proponents of behavior therapy to support this approach is the case of Little Hans. Little Hans was a boy who was deathly afraid of horses. A lot of children like horses, so his fear seemed at least a little strange. Why was Hans afraid of horses? According to psychoanalysis a mental or psychological explanation was that Hans’s fear of horses was a displaced fear of his powerful father. The behaviorists had a simpler explanation.
Hans had recently witnessed a number of extremely frightening events involving horses. On one occasion, he saw a horse die in a carting accident. This event made Hans very upset, and it scared him. The behaviorists proposed that the fear Hans developed from watching the horse die and from witnessing the other frightening, horse-related events had become classically conditioned to horses. He had associated fear with horses.
Remember how classical conditioning works? Here’s a little summary, but check out Chapter 8 for details.
Unconditioned Stimulus (Accident)→Unconditioned Response (Fear)
Conditioned Stimulus (Horse) + Unconditioned Stimulus (Accident)→Unconditioned Response (Fear)
Conditioned Stimulus (Horse)→Conditioned Response (Fear)
What do you get? Fear of horses à la classical conditioning. The beauty of this explanation comes from its implications for treating Little Hans’s horse phobia. According to behavior therapists, if he learned to be afraid of horses, he could learn how not to be afraid of horses. This type of result can be accomplished with a behavior therapy technique called systematic desensitization, which I cover in the Exposure-based therapies section later in this chapter.
Operant conditioning and behavior therapy
What about operant conditioning? What role does it play in behavior therapy? Take a look at anger, for example. If I get my way every time I get angry, I’m being positively reinforced for that behavior; therefore, I’m more likely to keep using anger in this way. This is a common explanation for a child’s behavior problems. If a child behaves in a manner that is not acceptable, her parents may be inadvertently reinforcing that behavior by providing attention to her that they may not provide in any other way.
An example of a negatively reinforced behavior is seen when an individual gives in to peer pressure. The ridicule a teenager endures for not going along with the crowd can be hurtful. He may give in to peer pressure just to put a stop to the ridicule (the removal of a painful stimulus).
Having a difficult time being assertive is a great example of a behavior, or the lack of that behavior, that is maintained through punishment. If I live in a home where I’m laughed at or otherwise punished for being assertive and speaking my mind, I’m far less likely to be assertive in other situations. I’ve been punished for being assertive. Lacking assertiveness can be a serious problem, and it often leads to feelings of victimization and resentfulness.
Behavior that is reinforced is more likely to happen again and again. If my angry outbursts for a sandwich get rewarded with a sandwich then I’m just going to keep on yelling. If my child’s tear-ridden tantrums get him out of homework then I can expect a tantrum each time the books get cracked. If I try to talk about my feelings with my parents and they ignore me, I’m going to keep those feelings to myself. If I’m punished for speaking my mind, then I’ll keep those thoughts to myself. Simply put, you get behavior that you reward; you don’t get behavior you don’t reward (or punish).
Social learning theory and behavior therapy
Humans learn by watching other people. A common problem in marriages involves fighting over money. This is sometimes a consequence of watching our parents fight over money, engaging in nonproductive, emotionally hurtful, and frustrating exchanges over who’s to blame for spending too much or not earning enough, for example. Modeling is a form of behavior therapy that is used to teach people new behaviors by showing them how to behave in a healthier way. I may ask that the husband begin a conversation with me about money and I can model, or show, the couple how to discuss money in a healthier manner. This only works, however, if the therapist knows how to model healthy behavior!
Behavior therapy, behavior modification, and applied behavior analysis
Broadly speaking, therapy conducted using the principles of classical and/or operant conditioning without particular concern for psychological or mental explanations is considered behavior therapy. Behavior therapy has also been called behavior modification (B-Mod) and is also known as applied behavior analysis (ABA). In many ways B-Mod and ABA are the same exact thing, therapeutic interventions that alter behavior through the application of the principles of classical and operant conditioning.
Honestly, not being a historian or sociologist, I am not exactly sure how the concepts of B-Mod and ABA became known as they did in their separate forms. As both an undergraduate and graduate student in California, I was always taught B-Mod but later on in my career I was exposed to ABA. As far as I can tell, different psychologists, researchers, and therapists in different parts of the country at different times in the 20th century developed different names for essentially the same therapy approach. Keep in mind that hard-core practitioners of ABA may suggest that ABA is a more comprehensive approach to behavior change that includes a specific set of data collection techniques, data recording, and applications beyond clinical psychology such as employee behavior in the workplace. Another thing that may, in fact, set ABA apart is that at its outset, it was specifically concerned with problem behavior such as aggression and self-injurious behavior that you often see in individuals who suffer from developmental disabilities, intellectual disability, or autism (for more on autism see Chapter 13.) Ultimately, however, I believe it really boils down to the old, “You say “to-mah-to,” I say “to-may-to.” So, you say ABA, I say B-Mod.
Assessing the problem
The simplicity of the behavioral approach to psychological problems is made possible with an equally simplified (but not easy!) set of practices. Behavior therapists put a lot of emphasis on the scientific method and its focus on observable changes and measurement. The therapy techniques and activities are well planned out, highly structured, and systematic. The therapist is viewed less as a holder of some divine truth and more as a collaborative partner in the behavior-change process. The patient is expected to pull his own weight outside of therapy, as well as in the therapy session itself, by completing homework assignments designed to change behavior in the real world and to further the progress made during each session.
In keeping with a systematic and scientifically based approach to psychological disturbance, behavior therapists begin by conducting a thorough assessment of the patient’s problem. Here’s a simple outline of the basic steps of behavioral assessment:
1. Identify the target behavior.
Step one involves taking a thorough look at the problem the patient originally presents to the therapist. Behavior therapists use a special technique called an ABC analysis to analyze the initial problem. The ABC analysis is an evaluation of the events that happen before, during, and after a target behavior (the patient’s problem behavior).
A. A stands for the antecedents of a particular behavior, the things or events that happen just prior to the target behavior. A common problem that behavior therapists encounter involves couples that argue excessively, so it serves as a good example. The particular antecedents of interest in the case of such a couple may be the time, place, and surrounding circumstances that immediately precede each argument.
Time: When each of them gets home from work
Place: Dinner table
Circumstances: Talking about each other’s day at work
B. B stands for behavior, as in the target behavior. In the case of the bickering couple, the target behavior is the act of arguing, itself.
C. C stands for the consequences of the behavior, or the events and general circumstances that occur after and are a direct result of B. In the case of the arguing couple, the Cs may be that both individuals get mad and stomp off, the man goes out for a drive, or the woman leaves the house to take a long walk.
2. Identify the present maintaining conditions.
Spiegler and Guevremont define the present maintaining conditions as those circumstances that contribute to the perpetuation of the behavior. They identify two specific sources:
• Environment: Conditions from the environment include time, setting, reactions from others, and any other external circumstances. This would be the who, what, when, where, and how of our arguing couple.
• Patient’s own The patient’s contribution includes his or her thoughts, feelings, and actions. This would be what each partner is thinking, feeling, and doing before, during, and after the arguments.
Exploring functions and outcomes
Functional Analysis of Behavior (FAB) is a more formal version of the behavioral assessment process. FAB (or FBA as some people call it) involves a specific approach to ascertaining the function of a particular behavior as it relates to the ultimate outcome it accomplishes. A behavior results in something happening and that something is the driving force behind the behavior. A child throws a tantrum because it works in accomplishing something for that child, maybe escape from the dreaded shopping trip with grandma. So the function of the tantrum is to escape the store.
The following are the most typical functions of behavior identified in an FAB:
Access to tangible rewards: Hitting gets me the toy I want.
Escape or avoidance of aversive stimuli: Screaming gets me out of doing chores.
Attention from others: Calling you names gets you to pay attention to me.
Automatic reinforcement: Scratching my skin relieves the itch.
After the patient and therapist figure out the function of the behavior, the therapist can formulate an intervention that may involve helping a person ascertain the desired function in a more appropriate manner, such as talking quietly instead of screaming.
3. Establish the specific goals of therapy in explicit terms.
The original therapy goal may be to stop arguing. However, this description is a little too vague for a behavior therapist’s liking. A more precise measure of the target behavior may consist of identifying specific numbers, occurrences, or lengths of time of the arguments. So, instead of the couple simply trying to stop fighting, a more fitting target behavior is to reduce their fighting to once a week.
Trying different techniques
Two of the nice things about behavior therapy for both the patient and the therapist are its clarity and structure. Behavior therapists can use a variety of highly structured treatment techniques to approach their patients’ problems. Spiegler and Guevremont identify three classes of behavior therapy techniques: reinforcement-based therapy, decelerating therapy and extinction, and exposure-based therapy.
Reinforcement-based techniques of behavior therapy are based on the principles of operant conditioning, specifically the use of positive reinforcement.
Bribing for basic school skills
I worked with autistic children by using applied behavior analysis, and one of the most challenging aspects of the therapy was finding reinforcers. The treatment consisted of using reinforcement to increase the children’s functional behaviors, such as communicating, socializing, playing, and learning basic school skills (recognizing letters, numbers, and colors, for example). The process consisted of teaching the target behaviors and reinforcing the children when they successfully performed them. But if the reinforcers had no reinforcing value, forget it.
Some children liked certain kinds of food or candy, so that’s what was used for them. Some liked certain toys or other objects, so those items were used too. If it improved their functioning, it was used. Some days, candy worked; other days it was toys. One child liked it when I pretended to bonk my head on the table, so I used that as a reinforcer. Hey, whatever works, right?
You may be thinking that all of this sounds like bribery. It is in a way. Sure, I bribed the kids to perform the goal behaviors, but think about the alternative. If I didn’t use reinforcement, the kids wouldn’t have learned these skills that have the power to improve the quality of their lives. I’d choose bribery over neglect any day.
After a thorough behavioral assessment, the therapist and the patient(s) follow these steps when participating in reinforcement-based therapy:
1. Identify a list of reinforcers to be used in the therapy.
This is a crucial process. Anything that’s likely to increase the probability of a desired behavior occurring again can be used as a reinforcer.
2. Determine how and when to administer the reinforcers.
Continuous reinforcement is the best way to get a quick jump on changing a behavior. Continuous reinforcement involves the patient receiving reinforcement every time she performs the target behavior. When the patient begins to consistently perform the new behavior, the reinforcement can be faded and only given once in a while, even randomly. This is the best way to keep a behavior going.
3. Begin shaping.
Shaping is a procedure in which successful approximations of the target behavior are reinforced in order to shape, move, or guide the patient toward the desired target behavior.
If the problem is studying and the target behavior has been identified as studying two hours a night without interruption, the student may be reinforced after studying for increasingly longer intervals leading up to the two-hour mark (20 minutes, then 30 minutes, then one hour, and so on) during the shaping process.
4. Create a formal contract that outlines all of the agreed-upon features of the treatment plan and clarifies when, how, and where the target behavior is to occur.
5. Conduct periodic reassessments throughout treatment to monitor the patient’s progress toward the goal.
Adjustments are made, as necessary, in the reinforcement procedures.
6. End therapy.
When the patient achieves the target behavior and maintains it for the desired length of time, therapy ends.
Deceleration and extinction therapies
Never cry wolf — most of us are familiar with this ancient warning. If I yell out for help too many times when I don’t need it, I won’t get help when I really do need it. But how long does it take for people to realize that I’m full of it? Don’t they know that I only keep crying wolf because they keep running to help? Basically, their response reinforces my crying-out behavior. It’s all their fault! All they have to do is ignore my pleas and stop running to my aid. That’ll get me to stop.
Collect your tokens, win a prize!
One of the more advanced forms of reinforcement-based therapy is the creation of a token economy. A token economy is a structured system of reinforcement that uses tokens, symbolic reinforcers that represent more tangible reinforcers, to increase the likelihood of a target behavior occurring. The best example of a token is money. Money in and of itself is useless, except maybe for the paper it’s printed on. (The paper can start a nice fire or be used as pillow stuffing.) The power of money comes from what it can bring us or what it represents — the ability to purchase tangible goods.
Token economies are often used in situations that require individuals or groups to follow a particular set of instructions or rules. Patients in a psychiatric hospital, for example, are often given points or other tokens for following institutional rules or performing one of their patient-specific target behaviors. In many cases, these tokens can be redeemed once a week at a snack or gift exchange. Some systems use tokens to help patients work toward leaving the hospital on small trips or excursions with the eventual goal of discharge in mind. This form of therapy is an excellent example of shaping.
The process of withholding or eliminating reinforcement, thus eliminating the response, is known as extinction. A long time ago, behaviorists figured out that a behavior stops when reinforcement stops.
Spiegler and Guevremont classify treatments that utilize the phenomenon of extinction as deceleration therapies. When the reinforcer that maintains a behavior is either withdrawn or withheld, the behavior eventually extinguishes. Deceleration therapy is conducted in much the same way as reinforcement-based therapy: Target behaviors and reinforcing conditions are identified. The main difference between the therapies is that reinforcers are withheld instead of given.
One of the best-known examples of deceleration therapy is the dreaded time out. Time out has become one of the most widely used disciplinary techniques by parents. The idea behind time out is that the undesirable target behavior of a child (or anyone for that matter) is being maintained by either the reinforcing social attention the child receives as a result of the behavior or some other reinforcer inherent in the situation itself, such as getting a toy away from another child.
When little Johnny performs the target behavior, he’s taken to a designated time-out area, thus removing him from whatever reinforcers are present in the situation. Also, no potential reinforcers should be present in the time-out area that could provide the child with reinforcement while on time out.
I’ve heard a lot of parents say that time out doesn’t work, but I often wonder if they’re actually doing it right. Spiegler and Guevremont point out four conditions that help make time out more successful:
Time-out time periods should be brief (five minutes or less), and the child should know how long the time period will last. A lot of parents leave their children in time out for too long. Younger children only need about one minute of time out for every year of their age — 4 years old: four minutes. Simple.
No reinforcers should be available during the time-out period. Using the playroom as a time-out area is not recommended. That’s like suspending a kid who hates school to begin with. Thanks!
Time out should end when the time is up and the child is behaving appropriately. If he or she is still acting up, extend time out for another designated time period.
Time out shouldn’t be used by kids as an escape to get out of doing things that they didn’t want to do in the first place. It requires some skill to determine when a child is manipulating the use of time out for this purpose. If children attempt to pull this trick, make them do whatever they were trying to avoid when they get out of time out.
There are several different types of therapy known as exposure-based therapies that involve “exposing” a target behavior to new conditions in order to reduce its occurrence. Exposure is another word for reassociating or relearning a target behavior with another behavior that results in the cessation of the target behavior.
Have you ever tried to smoke a cigarette while in the shower? It’s pretty hard to do. I once worked with a guy who managed to come up with a way to pull it off. (Interested? Sorry, I won’t support that habit by giving you the details.) Anyway, I’m guessing that most of us find that smoking and water don’t mix. These two actions are incompatible. Finding a behavior that interferes with a target behavior is a good way to stop the target behavior from occurring.
There are different therapy techniques that make use of this incompatibility concept. When two behaviors occur at the same time, the stronger behavior prevails. Water always wins over cigarettes. The behavior-therapist jargon for this concept is reciprocal inhibition or counterconditioning. Therapy that makes use of reciprocal inhibition or counterconditioning is designed to weaken the classically conditioned, negative target behavior. When you expose cigarettes to water, smoking is pretty hard to pull off. Counterconditioning is the operative mechanism of all exposure-based therapies.
Perhaps the best way to explain how counterconditioning drives exposure therapy is to talk about one of the most popular forms of exposure therapies, systematic desensitization (SD). SD is most commonly used to treat phobias, like fear of public speaking, social phobia, or some other specific phobia. Therapists have also used it to successfully treat panic disorder accompanied by agoraphobia. There are several types of exposure-based therapies based on the systematic desensitization principle:
Covert sensitization (imaginal exposure): The “learning” or associating is only occurring in the patient’s mind and not in real life.
The procedures that Wolpe and Jacobsen developed are very similar. Therapists teach patients how to enter a state of deep relaxation. Then they ask the patients to imagine themselves in the fear-producing, phobic situation, while maintaining their state of relaxation. When a patient’s anxiety level gets too high, the therapist asks the patient to let go of the image and continue to just relax.
When this process is repeated over and over again for several sessions, the fear response to the situation is diminished because the state of relaxation is competing with the original fear of the situation or object. Instead of fear, the patient now associates relaxation with the fear-inducing situation or phobic object.
Graduated-exposure therapy: When a patient learns to perform his feared behavior in a real-life situation, he or she is engaging in in vivo sensitization. Usually, this form of desensitization is done gradually, hence its name. If I’m afraid of flying, my therapist may start with me watching movies about flying (of course these should be movies about flying that don’t include a crash or some kind of airline disaster). Then I’d go to the airport; then I’d sit in the terminal; then go on an airplane. There’s a gradual move toward the eventual goal of flying, but not until I’ve done a lot of preparatory work and discovered how to relax during subsequent stages.
Flooding: This form of therapy involves exposing a patient to his or her fear-inducing situation or object for a sustained and prolonged period of time. The patient’s anxiety goes through the roof, so this can kind of sound like torture. If you’re afraid of snakes, jump into a tank full of them. You’ll either die or get over your fear of snakes! There’s no gradual exposure here. Just jump into a pit of snakes and get over it already!
It gets better! The patient is not only exposed to his worst fears, but he’s prevented from running away, leaving, or engaging in whatever escape behavior he’s typically used in the past to avoid the fear. This is called response prevention.
Flooding sounds horrible, but it’s actually one of the most powerful forms of behavior therapy. If a patient trusts her doctor, it can be a quick way to get over some powerful and debilitating phobias. It may seem cruel, but patients must consent to all treatment, and typically, people aren’t forced to go to any kind of therapy, unless it’s by the courts. (For more on the role of therapy in the criminal justice system, see Chapter 14.)
Getting in good with germs
A good example of flooding (see the Exposure-based therapies section in this chapter) comes from treating people with germ phobias. Let’s say that I was afraid of germs and catching diseases from trash cans. I managed to fill my entire apartment with garbage because I was too afraid to touch the trash in order to take it out. It was getting pretty rank in there, and my landlord was threatening to evict me. Luckily, I found a good behavior therapist in the neighborhood, and he agreed to help me.
When I met the therapist, he told me that he was going to do the therapy in my apartment. I thought that was pretty cool. When the therapist showed up, he explained that he was going to cure me of my germs-from-trash phobia. He pointed out a pile of trash and told me to jump in it. “Say what?” I said. “You heard me,” he replied, “jump in it!” The rest is history. I jumped in the pile of trash and began to roll around. After my garbage swim session, the therapist refused to let me take a shower until the next day. I complied, and I no longer fear trash.
Keep in mind that this is not a true story, and it’s a pretty extreme example of flooding, but it’s not that far from the truth. Therapists who use flooding ask their patients to completely expose themselves to the things they fear the most. Believe it or not, it actually works!
Applying Some Soap to Your Mind with Cognitive Therapy
Alcoholics Anonymous uses the term “stinking thinking” to describe the kinds of thoughts that a recovering alcoholic has when he thinks negatively and contemplates taking a drink. The simplicity of this statement should not be mistaken for a lack of wisdom. The power of thought should never be underestimated.
Cognitive therapy is a popular and well-researched form of psychotherapy that emphasizes the power of thought. From the perspective of cognitive therapists, psychological problems such as interpersonal difficulties and emotional disorders are the direct result of “stinking thinking.” In other words, maladaptive thought processes or cognitions cause these problems. “Stinking thinking” can have a tremendous impact on our psyche because people analyze and process information about every event that occurs around them and their reactions to all of these events. Maladaptive thinking can go something like this:
A (losing my job)→B (my thoughts about getting fired)→C (my emotions and subsequent and more exaggerated thought processes about the event)
People’s reactions are the product of how and what they think about a situation or event. In many situations, such as the experience of loss, an insult, a failure, or encountering something scary, it’s only natural to feel some negative emotion. Negative reactions are not necessarily abnormal. It’s only when emotional and behavioral reactions become extreme, fixed, and repetitive that people start down the path of psychological disturbance.
Exploring distorted thinking
Sometimes thinking can be biased or distorted, and this can get people into trouble. Cognitive therapy approaches reality from a relativistic perspective: An individual’s reality is the byproduct of how he or she perceives it. However, cognitive therapists don’t view psychopathology as simply a consequence of thinking. Instead, it’s the result of a certain kind of thinking. Specific errors in thinking produce specific problems.
If you lost your job, it would be natural to think, “I need to find another job.” But you would be distorting reality if you thought, “I’m never going to find a new job.” This kind of pessimistic thinking is bound to produce a stronger than usual negative emotional reaction. There’s a world of difference between “I need a new job” and “I will never get another job.”
Peale is so positive
Norman Vincent Peale’s The Power of Positive Thinking (Ballantine Books) is now one of the most famous self-help books on the market. Peale’s basic idea is that positive thinking produces positive results in people’s lives. He believes that our thoughts play a central role in the production and maintenance of behavior.
Aaron Beck identified six specific cognitive distortions that lead to psychological problems:
Arbitrary inference: This distortion occurs when someone draws a conclusion based on incomplete or inaccurate information. If a couple of scientists are asked to describe an elephant, but all they can see of the elephant is what’s visible through a small hole in a fence, each scientist’s elephant description will probably be different. One scientist looks through the hole and sees a tail. Another looks through and sees a trunk. The first scientist describes an elephant as an animal with a tail, and the other says that it’s an animal with a trunk. Neither one of them has the complete picture, but they both think that they know the truth.
Catastrophizing: My grandmother used to refer to this distortion as “making a mountain out of a molehill.” Beck defined it as seeing something as more significant than it actually is.
Dichotomous thinking: Most of us know that thinking only in terms of black and white, without considering the gray areas, can get us into trouble. When I categorize events or situations into one of two extremes, I’m thinking dichotomously. While working in prisons, I’ve found that inmates often separate people into two groups — friend or foe. “If you’re not my friend, you’re my enemy.”
Overgeneralization: “My boyfriend dumped me; no one loves me.” This is an example of overgeneralization — when someone takes one experience or rule and applies it across the board to a larger, unrelated set of circumstances.
Personalization: One of my favorite movies is Tempest, the1982 move directed by Paul Mazursky starring John Cassavetes, Gina Rowlands, and Susan Sarandon. Toward the end of the movie, the main character thinks that he summoned a storm that capsized his enemies’ boat. Personalization occurs when someone thinks an event is related to him or her when it actually isn’t.
Selective abstraction: I once knew a guy in college who believed that women always laughed at him when he walked by them on campus. Little did he know that most of the women probably didn’t notice his existence. They were most likely laughing at a joke or some other funny situation that had nothing to do with him. He arrived at a conclusion by taking their behavior out of context.
The theory underlying cognitive therapy is beautiful in its simplicity. If psychological problems are the products of errors in thinking, therapy should seek to correct that thinking. This is sometimes easier said than done. Fortunately, cognitive therapists have a wide range of techniques and a highly systematic approach at their disposal.
Changing the way you think
The goal of cognitive therapy is to change biased thinking through logical analysis and behavioral experiments designed to test dysfunctional beliefs. Many thinking errors consist of faulty assumptions about oneself, the world, and others. Cognitive therapy usually goes something like this:
1. The therapist and patient perform a thorough assessment of the patient’s faulty beliefs and assumptions and how these thoughts connect to specific dysfunctional behaviors and emotions.
Christine Padesky and Dennis Greenberger, in their book Mind Over Mood (Guilford Press, 1995), provide the patient with a system for identifying these thinking errors, which cognitive psychologists commonly call automatic thoughts — thoughts that occur automatically as a reaction to a particular situation. The patient is asked to keep track of specific situations that occur between therapy sessions and to identify and describe in detail his reactions to those situations.
2. The therapist and patient work together, using the automatic thought record, to identify the cognitive distortions mediating between the situations and her reactions.
This often-difficult process can take anywhere from several weeks to several months, but at the end of the process, the distortions have been thoroughly identified.
3. The therapist and patient work collaboratively to alter the distorted beliefs.
The therapist and patient collaborate in a process of logical refutation, questioning, challenging, and testing of these faulty conclusions and premises. This effort attempts to make the patient a better thinker and break him of the habit of poor information processing.
One of the best-known applications of cognitive therapy comes from Aaron Beck’s cognitive therapy of depression. Beck proposes that depressive symptoms, such as a sad mood and a lack of motivation, are the result of cognitive distortions based on three very specific beliefs that the patient holds about himself, the world, and the future. Beck called these beliefs depressogenic assumptions, and they exist in a cognitive triad. The cognitive triad of individuals suffering from depression consists of the following basic beliefs:
I am inadequate, deserted and abandoned, and worthless.
The world is an unfair and harsh place. There’s nothing in it for me.
There is no hope for the future. My current troubles will never go away.
These beliefs interfere with reasonable and healthy adaptation and information processing concerning events in the patient’s life. The challenge for both the patient and therapist is to come up with ways to identify, challenge, and alter these beliefs in order to reduce their impact on the patient’s emotions and motivations.
Playing Together Nicely: Behavior and Cognitive Therapies
Albert Ellis was the founder of a combined form of therapy that borrows from both behavior therapy and cognitive therapy. Rational emotive behavior therapy, or REBT, is built on the premise that psychological problems are the result of irrational thinking and behavior that supports that irrational thinking; therefore, they can be addressed by increasing a patient’s ability to think more rationally and behave in ways that support more rational thought.
Ellis is a charismatic psychologist whose style and personality accentuate the main ideas of REBT. Rational emotive behavior therapists believe that most of our problems are self-generated, and that people upset themselves by clinging to irrational ideas that don’t hold up under scrutiny. The trouble lies in the fact that many people don’t scrutinize their thoughts very often. People make irrational statements to themselves on a regular basis:
“I can’t stand it!”
“This is just too awful!”
“I’m worthless because I can’t handle this!”
These are examples of irrational thinking. Rational emotive behavior therapists define these statements as irrational because they argue that people can actually handle or “stand” negative events. These events are rarely, if ever, as bad as people think they are. Also, people often hold themselves to rules of “should” that increase their guilt for being overwhelmed, sad, anxious, and so on. “I shouldn’t get angry.” “I shouldn’t care what she thinks.” “I shouldn’t worry about it.” Ellis used to call this “shoulding all over yourself.” REBT therapists vigorously challenge statements like these.
The challenging posture of REBT should not be taken as harsh or uncaring. REBT emphasizes the same levels of empathy and unconditional acceptance as many other therapies. REBT therapists are not necessarily trying to talk patients out of feeling the way that they feel. They’re trying to help patients experience their emotions in a more attenuated and manageable fashion. There are healthy levels of emotion, and then there are irrational levels of emotion. The goal of therapy is to help the patient learn how to experience her emotions and other situations in this more rational manner.
The behavior-therapy aspects of REBT involve the patient engaging in experiments designed to test the rationality or irrationality of his beliefs. A therapist may ask a patient who is deathly afraid of talking to strangers to approach ten strangers a week and strike up a conversation. If the patient originally thought that he was going to die from embarrassment, the therapist may begin their next session with, “Nice to see you. I guess talking to strangers didn’t kill you after all, did it?”
REBT takes the position that two approaches can bring about changes in thinking — talking with a therapist and rationally disputing irrational ideas, and engaging in behaviors that “prove” irrational ideas wrong. Ellis states that people rarely change their irrational thinking without acting against it. Their thinking won’t change unless their behavior changes.
Being Aware with Acceptance and Mindfulness-Based Therapies
Therapy is certainly about change. Change your behavior. Change your thinking. Behavior and cognitive therapies are consistent with this. But change is hard, right? I’ve failed at change and I’m pretty certain you know somebody who has as well. Change is a multibillion dollar industry. Just peruse the “self-help” section of the local bookstore. But what do you do with all this failure to change? How can you change your failure to change? This is exhausting to write about, let alone live with.
Luckily, a group of therapies classified broadly as “acceptance and mindfulness-based” therapies have been developed that put the issue of change front and center. At the core of these therapies is the concept of acceptance, defined within the therapies as helping patients stop struggling with the change process and helping them experience their lives, emotions, thoughts, and behavior in a direct, nonjudgmental, open-minded, and accepting manner. Two well-researched and popular forms of acceptance and mindfulness based therapies are ACT (acceptance and commitment therapy) and MBCT (mindfulness-based cognitive therapy).
According to these therapies, a patient’s lack of acceptance of his life, emotions, history, and so on is part of the problem; it is part of the pathology for which they visited a therapist for in the first place. Rather than change behavior as in behavior modification or thoughts as with cognitive therapy, there is an emphasis on changing the way a patient approaches his behavior, thoughts, and so on. A patient is changing the way he views and interacts with his issues, history, and problems. It’s kind of like stepping back, or stepping away for a different perspective, a nonjudgmental perspective.
The mindfulness component involves being aware of the real and present moment and staying open to the ongoing thoughts, sensations, and feelings without trying to change, alter, or modify them. Facing these things with acceptance and mindfulness is therapeutic. Stephen Hayes, a key developer of ACT, states that certain aspects of how human language works results in avoidance, rather than acceptance and mindfulness. People “talk” to themselves and about themselves, others, and the environment in ways that lead to avoidance and a lack of acceptance.
But it isn’t all about acceptance. A key decision point for therapists is whether and when to help patients accept or change at any given point or with any given situation. This decision is based on evaluating situations or circumstances using two criteria, changeability and justifiability:
Is the situation changeable? If something is not changeable, such as the death of a loved one, then focusing on changing that situation would not lead to psychological health. If a situation is changeable, such as whether or not you can stop drinking soda, then it should be a focus of change. Change what can be changed, accept what cannot. Can anyone say Serenity Prayer?
Is the reaction justifiable? The “justifiable” aspect of a patient’s thinking, emotions, or behavior involves an analysis of whether or not a patient’s reactions are in proportion to and related to an actual event or situation or if they are out of line or overreactions. If a reaction is not justified, then solving the problem that triggered the reaction doesn’t make sense because there was no real problem to solve, just an overreaction. If the situation or circumstance is changeable, then change it; if not, then adopt an accepting attitude toward it. If your reaction is justifiable, then accept your reaction or change your reaction. If it is not a justifiable reaction, then just accept the reaction, non-judgmentally and mindfully.
You’re Okay, Now Change: Dialectical Behavior Therapy
Dialectical behavior therapy, the brainchild of Dr. Marsha Linehan, is a therapy approach that combines the behavioral, cognitive, and mindfulness approaches. DBT was originally developed for individuals diagnosed with borderline personality disorder who were engaging in self-injurious behavior (such as cutting themselves) and who were at high risk for suicide. Since its inception, however, DBT has been used with a much wider range of problems and patients and is considered one of the most well researched and empirically based therapies in clinical psychology.
DBT is considered a very comprehensive intervention that includes individual therapy and a range of consultative approaches to a client’s problems and skill-building approaches (such as social skills training). In many of its behavior and cognitive approaches, it’s not necessarily all that unique from other behavior and cognitive approaches. One aspect that certainly sets DBT apart, however, is the inclusion and centrality of acceptance and mindfulness components.
A key acceptance and mindfulness feature of DBT is found in the name of the therapy itself, Dialectic. Dialectic refers to the broad concept that reality is interconnected, made up of opposing forces and forms, and dynamic and constantly changing. A dialectic view of things would hold that something can be two seemingly contradictory things or in two contradictory states at the same time. A patient can both want to change and not want to change at the same time. The central dialectic in DBT is focused on the opposing forces of acceptance and change. Patients are taught how to change and are expected to change but are also taught how to and are expected to work on acceptance of themselves, their past, and the world.
DBT respects and responds to the all-too-often reality that people coming to therapy can feel pushed too hard to change and as a result will drop out of therapy early. Focusing too much on change may be emotionally overwhelming, feel invalidating, or even feel shaming. It is critical to strike a balance between acceptance and change. This balance is sought and achieved with a variety of techniques including training in mindfulness. Dr. Linehan outlines the following key components of mindfulness:
Observing: Simply experiencing the present moment, thoughts, emotions, bodily sensations, and so on
Describing: Describing the present moment without judgment
Participating: Throwing oneself into an activity without self-consciousness
DBT mindfulness involves paying attention to the current, moment-by- moment reality and in a non-reactive manner, responding to the facts rather than the patients’ own thoughts, emotions, or other reactions. This engenders acceptance, facilitates effective problem solving, and reduces avoidance. The patient has to be willing not to resist reality and to resist engaging in “as if” or “it shouldn’t be this way” thinking, or insisting something is true or real when in fact it is not. This willingness then facilitates more effective problem solving and reduces reactivity over time.