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

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?

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

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.

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.

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.

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

You write "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?"

In this statement you seem to be talking as though cognition is restricted to "conscious language." Beck defines cognition much more broadly than this. In fact, he asserts that the cognition involved in both "primary appraisal" and "secondary appraisal" is automatic, operates outside of conscious awareness, and isn't necessarily verbally mediated. For example, if you are out walking in the woods one day, turn a corner, and find a bear standing in front of you, you probably will not have words running through your mind saying "Oh my goodness! A bear! It will eat me! I must run away!" Instead, you will quickly and automatically appraise the situation, conclude that the bear presents a threat, conclude that "flight" is more promising than "fight" and act on this behavioral inclination. You will also feel afraid.

These appraisals are based on your schema about bears, woods, and hikers and if your schema is erroneous in some ways, your appraisal and subsequent responses are likely to be dysfunctional.

Most people assume that one feels afraid and therefore runs away. However, Beck argues that the affect and the behavioral inclination are two independent products of the appraisal of the situation. Afterall, humans are quite capable of being afraid but not running away or of running away even though they are not afraid.

CT includes non-conscious appraisals, mental imagery, and "conscious language" as different aspects of cognition, we do not limit ourselves to just addressing conscious language.

To read about this nonconscious language idea is surely not what Albert Ellis presents. My understanding of the historical precedents was that psychoanalysis paid limited homage to the 'conscious thought process', and that the emergence of cognitive behavior modification was very much centered on using this very conscious thought process as the primary vehicle through which to create behavior change. This represented back then a bold attempt to get away from the mysterious ideas of the psychoanalytic 'unconscious' and the operation of equally unconscious 'defense mechanisms'. To now read about discussions of automaticity and psychological defenses and dreams, and transferences, and issue of communication within the therapy room is a bit befudddling to say the least. I'm presuming I'm going to be reading now about how all these things will reformulated into CT terms. And then there's going to be research about all this??? I can only say that anyone who has ventured into psychoanalytic literature concerning these topics knows that a never ending quagmire awaits (whether or not one believes in psychoanalytic theory or practice, the nature of therapeutic communcation and the therapeutic relationship and when and how a therapist intervenes certainly, I think, has lots of relevance for any of the 'talking' therapies). Unfortunately, this topic introduces more variables and more compexity.

So I'm confused, because while I really do appreciate this more complicated (and realistic) understanding of mental life and that thoughts are not so conscious and manipulable--- it just looks like to me that things are headed in a direction where we all sigh--- agree this is art and not science--- but keep building a whole new edifice of marginally testable ideas anyway along with new mountains of literature whose basic tenets are going to be shakey at best.

Do we have to know the theory and the inner workings to believe that or to know that "CT works". Dr. Pretzer I've heard this before. From the Family Therapists. From the Analysts. From the Operant Conditioning People. From the Gestalt therapists. The subjective evaluation that therapy 'works' (and that this is more important than theory) because my experience and my colleagues experience and research tells me so is a little troubling. This is how the whole psychotherapy enterprise has always proceeded. And similar too is the idea that all the major CT researchers happen to be CT proponents and they pronounce that CT works too!! It's an odd, but long time state of affairs that double blind studies--and really long term studies-- and a full appreciation of the innumerable interacting variables just seems to elude us.

But forgetting for a minute about cognitions and conscious or unconscious or automatic--- you circumvented my question about basic affects being present at birth and the developmental implications of conscious or unconscious thought process developing later. Doesn't this say something about the primary place of 'affect' in mental life, and whether the tail may be wagging the dog, by giving cognition primacy?

-Doug