The New

Handbook of
Cognitive
Therapy
Techniques
Rian E. NcHullin
 The Heui Handbook of
Cognitive Therapy
Techniques
Rian E. Me Mullin
T h is h o w -to re fe r e n c e provides th e th erap ist
w ith an im m ed ia tely u sable gu id e to co g n itiv e
therapy. It d escrib es, explains, and d e m o n ­
stra tes o v er a h u n d red c o g n itiv e th erap y
tech n iq u es, o ffe rin g fo r ea ch th e th e o retica l
basis, a th u m b n ail d escrip tio n o f th e m eth o d ,
ca se ex am p les, and re s o u rce s f o r fu rth e r
in fo rm atio n .
C o g n itiv e re s tru c tu rin g th era p y is based
o n th e tru th : I f w e change our thoughts , we
change ourselves. It tack les, w ith lo g ic , p ersis­
te n ce , and creativ ity , th e d isto rted beliefs
u n d erly in g o u r em o tio n a l resp on ses to ev ery ­
day ev en ts. W it h d ozens o f so ft, h ard , and
o b je ctiv e c o u n te r in g tech n iq u es, as w ell as
m eth od s to en co u ra g e p ercep tu al sh ifts, this
b o o k is a h u g e to o lb o x fo r co g n itiv e therapy
p ractitio n e rs.
In th is m a jo r re v is io n of h is 1986
H an d book o f C ogn itive T herapy Techniques ,
M e M u llin has added seven new ch ap ters,
w h ich explain how to te a c h basic co n cep ts,
h ow to u n cov er h arm fu l sch em as, and how to
resy n th esize h isto rica l and cu ltu ral b eliefs.
H e d irects special a tte n tio n to u sin g these
s tra te g ie s w ith a d d icted c lie n ts and w ith
severely m en ta lly ill p a tien ts. I n ad d itio n , he
has trip led th e n u m b er o f exam p les, dia­
lo g u es, case tra n scrip ts, and illu stration s.
W h e th e r th e y are new to co g n itiv e th e ra ­
py o r have been u sin g it fo r years, clin icia n s
w ill find h ere a ric h , en g a g in g , p ractical
reso u rce.
The NEW Handbook
of
Cognitive Therapy
Techniques
The NEW Handbook
of
Cognitive Therapy
Techniques

R ian E. Me M u l l i n , P h .D.

f> rr
W. W. Norton & Company
New York London
 Book cover from Feeling G ood: T he N ew M o o d T herapy by David D. Burnes, M. D. (Avon Books,
1992) on p. 33 is reprinted by permission o f HarperCollins Publishers, Inc.

The poetry on page 434, from 'The Secret Sits", is from: THE POETRY OF ROBERT FROST,
EDITED BY Edward Connery Lathem. Copyright 1942 by Robert Frost. Copyright © 1979 by
Lesley Frost Ballantine. Copyright, © 1969 by Henry Holt and Company, LLC Reprinted by
permission o f Henry Hold and Company, LLC.

Copyright © 2000, 1986 b y Rian M e M ullen

Previous edition published as H A N D BO O K O F C O G N ITV E TH ERA PY T E C H N IQ U E S

All rights reserved

Printed in the United States o f Am erica

For inform ation ab o u t perm ission to reproduce selections from this book, w rite to
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The text o f this b o o k is com posed in N ofret and Eras w ith th e display set in M ram o r
M anufacturing b y H addon Craftsm en
B ook design and desktop com position b y Justine Burkat Trubey

L ib rary o f C on g ress C a ta lo g in g -in -P u b lic a tio n D ata

M e M ullin, Rian E.
The new h an d b oo k o f cognitive therapy techniques /
Rian E. M e M ullin. - [Rev. ed]
p. cm.
Rev. ed. of: H andbook o f cognitive therapy techniques / Rian E. M e M ullin
N ew York: N orton. 1986.
"N orton professional book."
Includes bibliographical references and index.
IS B N 0 - 3 9 3 - 7 0 3 1 3 - 4
1. Cognitive therapy H andbooks, m anuals, etc. I. M e M ullin, Rian E.
H andbook o f cognitive therapy techniques
RC 489.C 63M 36 1999
616.89'142-d c21 9 9 -1 6 3 9 0 CIP

W. W. N orton & Com pany, Inc., 5 0 0 Fifth Avenue, N ew York, N.Y.

w w w .w w norton.com

W, W. N orton & Com pany, Ltd., Castle House, 75/76 Wells Street, L ondon W I T 3Q T

* 6 7 89 0
 /

Contents

P re fa c e ix
A c k n o w le d g m e n ts xiv
In tro d u c tio n 1

1. TEACHING THE ABCs 7

Teaching th e Basic Form ula 8
P roviding E v id en ce that Beliefs P rodu ce Em otions 14
How Powerful Are E n v iron m en tal Forces? 23
Learning th e Concepts 31

2. FINDING THE BELIEFS 37

E xp ectation s 38
S elf-E fficacy 43
S e lf-C o n ce p t 46
A ttention 51
Selective M e m o r y 53
A ttribution 58
E valuations 60
S e lf-In stru ctio n 64
T he H idden C ognition 68
Explanatory' Style 72

3. GROUPS OF BELIEFS 76
C ore Beliefs 76
Life T h em e s 80
C ognitive M ap s 84
 Contents

4. COUNTERING TECHNIQUES: HARD 88

C ou nterattackin g 92
C ou n terassertion 96
Disputing and C hallen g in g 100
Forcing C hoices 102
Creating D isso n an ce 110
C ognitive Floo d ing 116
Cognitive Aversive C on d ition in g 121
C ognitive Escap e C on d ition in g 125
Covert A voidance 128

5. COUNTERING TECHNIQUES: SOFT 1 32

Relaxed C ou n terin g 132
A nticatastrop hic Practice 136
C oping Statem en ts 140
C overt Extinction 143
N onp atholog ical T h in kin g 149
Covert R ein fo rcem en t 153
Use o f Altered States 156

6. COUNTERING TECHNIQUES: OBJECTIVE 159

A lternative Interpretation 163
R ational Beliefs 167
Utilitarian C ounters 169
D epersonalizing S e lf ]72
Public M ea n in g s 175
Disputing Irrational Beliefs 178
Logical Analysis 180
Logical Fallacies 194
Finding th e G o o d R eason 203

7. PERCEPTUAL SHIFTING: BASIC PROCEDURES 208

Basic Perceptual Shift > 211

8. PERCEPTUAL SHIFTING: TRANSPOSING 217

Transposing Im ages 218
Difficult Transpositions ??8
Progressive Im a g e M o d ificatio n 241
 /

Contents _______________________ vy
/

R ation al E m otiv e Im ager)' 245

Im ag e T ech n iq u es 249

9. PERCEPTUAL SHIFTING: BRIDGING 256

Bridge Perceptions 258
H ierarchy o f Values Bridges 262
Label Bridges 266
H ig h e r-o rd e r Bridging 269

10. HISTORICAL RESYNTHESIS 276

R esyn th esizin g Critical Life Events 277
R esyn th esizin g Life T h em es 285
Resynthesizing Early R ecollections 289
Resynthesizing Family Beliefs 298
Survival and Beliefs 501

11. PRACTICE TECHNIQUES 307

Visual Practice 508
A uditory Practice 509
R o le-p la y in g 510
E n v iro n m en ta l Practice 515
Diary R esearch and Practice 519
G u ided Practice 525

12. ADJUNCTS 528

Crisis C ognitive T h erapy 528
Treating Seriou sly M en ta lly 111 Patients 552
H andlin g Client Sab o ta g es 540
C ognitive Restructuring Therapy w ith Addicted Clients 550
C ognitive Focusing 576
C ore C o m p o n e n ts o f C ognitive Restructuring Therapy:
A Checklist 585

15. CROSS-CULTURAL COGNITIVE TH ERAPY 392

Referen ce G roups 592
C ultural C ategories 596
Cultural Beliefs 405
C ou n selin g in Different Cultures 410
Cultural Stories an d Fables 417
 C ontents .

1 4 . PHILOSOPHICAL UNDERPINNINGS 425

W h a t Is R ational to Clients? 425
W h a t Is Real to Clients? 432

B ib lio g ra p h y 439
In d e x 473
 /

Preface

T h is is for the practicing therapist. It is not a

c l i n i c i a n 's h a n d b o o k
t e x tb o o k o n th e o ry or research. I presum e the reader has already
learn e d th e b asic theoretical know ledge o f cognitive therapy and has
read o n e or m o re o f th e m a n y fine b o o k s available o n th e subject,
su ch as th e w orks o f A lbert Ellis (1995, 1996), Aaron Beck (1993, 1996),
M ich ael M a h o n e y (1991, 1995a), D on ald M e ic h e n b a u m (1977, 1994), or
A rth u r Freem an (Freem an & Dattilio, 1992).
I w ish to give th e practicing therapist an im m ediately usable guide.
W h ile w ritin g each section, I m ain ta in ed a precise focus: I pictured the
read er as an ex p erien ced therapist facing a full caseload each day.
W h a t w o u ld therapists need to know to try o n e o f th e tech n iqu es with
a n u p c o m in g client? W h a t problem s m ight they en cou n ter? W h a t
sn ares m ig h t present ob stacles? Is there a h a n d o u t they could give
th e ir client? How well would a session's transcript give therapists a
feeling for th e tech n iq u e? W h at exam p les w ould best help therapists
to try th e te c h n iq u e th e next day with o n e o r m ore o f their clients?
This b o o k is a h o w -to reference for therapists and cou nselors w ho
r en d er service in a variety o f settings (public an d private clinics,
schools, hospitals, a n d c o rp o ra te health centers). It is designed to tar­
g et practitioners w an tin g to e n h a n c e their effectiveness with clients in
need o f cogn itiv e therapy.
A lth ou gh b a sed o n m y earlier work, H a n d b o o k o f Cognitive Ther­
apy T ech n iq u es (M e M ullin, 1986), this b o o k is a co n sid e ra b le revision
o f th e earlier text. I added three ch ap ters o n teaching the b a sic c o n ­
cepts, d iscov ering th e client's beliefs, and g ro u p in g th e clients key cog­
nitions. T hese sections w e re om itted in the first edition b ec a u se this
in fo rm atio n w as presented in m y 1981 pu blication (Me M ullin &
X P reface

Giles). Sin ce this earlier w o rk is n o lon g er readily available, I have

added so m e o f th e in fo rm atio n to th e p resen t h a n d b o o k .
I ex p an d ed the presentation o f cogn itiv e c h a n g e te c h n iq u e s by
tripling th e size o f th e c o u n te rin g section and su b d iv id in g it in to th ree
chapters b e c a u s e fu rther clinical e x p e rie n c e has sh o w n m e th a t clients
respond differently to different types o f cou n ters. T h e p e rce p tu a l shift
section also has b e e n rew ritten and ex p a n d ed to th ree ch ap ters so that
the therapist will h av e a clearer idea a b o u t h o w to use th ese in ter­
ventions.
I added tw o new chapters on resynth esizing historical a n d cultural
cogn ition s b e c a u s e th ese te c h n iq u e s have ta k en o n m o r e im p o rta n c e
in recent years. All practice te c h n iq u e s h av e b e e n g ro u p e d in o n e
ch ap ter to m ak e it easier for th e reader to u se them . I h av e d rop p ed
th ree chapters and su b su m ed so m e o f th e in fo rm a tio n in to o th e r sec­
tions w h ere th ey are m o r e relevant. I added tw o sections o n c o u n s e l­
ing clients with drug and alcoh ol p rob lem s and w o rk in g w ith severely
m en ta lly ill patients. I d rop p ed th e research a p p e n d ix b e c a u s e e x te n ­
sive research in the last ten years has provided strong su p p o rt fo r c o g ­
nitive th erapy (J. Beck, 1995; D ob son, 1989; Elkin et al., 1989; Sh ea et
al., 1992), m a k in g th e a p p e n d ix superfluous. Finally, I added a short
ch ap ter on the p h ilosop h ical fo u n d a tio n o f cogn itiv e restructuring
therapy.
The m ain c h a n g e in th e b o o k is th e increased n u m b e r o f clinical
exam ples. M o st o f th e letters I received fro m therapists a b o u t m y e a r­
lier works show ed that readers like clinical stories b e c a u s e th e y help
th e practicing therapist to un derstan d h o w to ap p ly th e tech n iqu es. In
ord er to c o n v e y th e flavor o f cogn itive therapy, I tripled th e exam ples,
dialogues, transcripts, a n d stories. All th e cases are true, b u t I have
ch an ged n am e s an d o th e r in fo rm a tio n th a t w ould reveal th e identity
o f the client. In the tradition o f a h a n d b o o k , rath er th a n a te x tb o o k , I
included instru ctions to clients, patien t handouts, parts o f clien t m a n ­
uals, ex am p le s o f h o m e w o rk sheets, a n d m a n y figures an d illustra­
tions. Transcripts o f sessions w ere ed ited to avoid u n n ecessa ry
repetition and to m ak e oral c o m m u n ic a tio n m o re readable.
I included o n ly those te c h n iq u e s that m y colleag ues a n d I have
used ex ten siv ely w ith a variety o f clients. This h a n d b o o k is not sim ­
ply a survey o f all cogn itiv e tech n iq u es develo ped b y all c o u n selo rs
w h o call th em selv e s cogn itiv e therapists. A lth ou gh th e overall ph ilos­
o p h y o f the b o o k is co g n itiv e -c o n stru c tio n istic ra th e r th a n rationalis­
tic (Ellis, 1988b; G u id ano, 1991; M ahoney, 1988, 1991, 1993b, 1994;
Preface._______________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ xi
/

Neimeyer, 1993), 1 was interested o n ly in u sable techniqu es, not those

th at sim p ly fit a specific th eoretical m odel. I discuss cognitive b e h a v ­
ioral te c h n iq u e s as well as rational em o tiv e b e h a v io r th erapy proce­
dures. If I fou nd a te c h n iq u e helpful with the variety o f clients my
c o llea g u es and I have counseled, I includ ed it.
If th e read er finds o n e o f his o r her favorite tech n iqu es not
included, it is b e c a u s e w e did n o t find it useful, w ere unaw are o f it, or
b e c a u s e w e arbitrarily em ployed a n o th e r approach.
I take full respon sibility for th e tech n iqu es described in this book.
T h ey w ere develo ped over 2 7 years o f therapy ex p erien ce with differ­
ent types o f clients from m a n y different cultures. However, these tech­
niques, like all p sy ch o th erap eu tic procedures, develo p ed from the
c o m m o n pool o f pu blished reports and b o o k s and from discussions
a m o n g colleagues. I h a v e attem p ted to give credit for a technique, or
an asp ect o f a techniqu e, w h en I could identify its origins, b u t years
o f practice, and free-flo w in g creative th ou gh t have m ad e it im possible
for m e to alw ays pinp oint th e exact source. If I h av e slighted so m e o n e
in m y references, it is u n in ten tio n al and I apologize for the oversight.

O u t l in e

T h e m ain e m p h a sis o f th e first ed ition was on the last step o f cog­

nitive th erapy— h elp ing clients to c h a n g e th eir d am agin g beliefs, to
shift their p ercep tion s fro m b e in g destructive and harm ful to b ein g
m o re p ro m o tiv e a n d useful.
T h e p resent edition is m o re com p reh en siv e in that it includes the
full ran ge o f te c h n iq u e s th a t cogn itiv e therapists need to w ork with
clients. T he te c h n iq u e s are presented in the ap p ro x im a te ord er thera­
pists use w h e n co u n selin g clients.
W h ile universities th o ro u g h ly train m ental h ealth professionals to
help clients, after grad u a tio n w e are still ill eq u ip p ed to con v erse with
"real" people. O ften w e attend four years o f u n d erg radu ate college,
five years o f grad u ate o r m edical school, and o n e o r two years o f post­
d o c to ra te in tern sh ip o r residency. During th ese eleven years o f train­
ing, w e read h u n d red s o f professional b o o k s and thou sands of
research articles, all for o n e purpose— to help us co u n sel future clients.
T h e o n ly difficulty w ith all o f this university e d u catio n is that we
sp e n d m ost o f o u r tim e talking to college professors and fellow pro­
fessionals. C onsequently, b y the tim e w e see o u r first real clients, our
XII___________________________________________________________________________________E reeace

la n g u a g e has b e c o m e so e n m e sh e d with ja rg o n an d in c o m p r e h e n s i­
ble lingo th a t m a n y clients h av e difficulty u n d erstan d in g us.
W h en we start o u r practices, m a n y o f us talk in an acad em ic, g r a d -
u ate/ m ed ical-sch ool dialect like th e following:

T he p u rp o se o f this initial diagnosis is to ascertain th e in ten sity

o f various p a tholog ical sym ptom s. We, o f course, will b e em p ir­
ical in o u r search, an d will cast a g lan cin g eye at etiology.

Predictably, th e client's resp o n se is, "W hat?" o r "H uh?" It takes so m e

o f us years to learn to say, "How d o you feel? W h at's b o th e r in g you?"
or "How m a y I help?" In th e exam ples, scripts, and d ialo gu es o f this
h a n d b o o k , I h av e tried to u se th e v e rn acu la r w h e n e v e r I c o u ld to
sh ow the style o f c o m m u n ic a tio n m y colleag ues and I h a v e learn ed to
use with clients.
The h a n d b o o k can b e read b y g o in g to th e c h a p te r m o s t p e rtin en t
to readers' needs, b u t m o st readers w ould find it helpful to rev iew th e
finding beliefs chapters (1 throu g h 3), an d to b e fam iliar w ith th e basic,
cognitive c h a n g e chapters (4, 5, 6, 7, and 11). I in clu d e a s u m m a r y o f
th e chapters to h elp readers m a k e th eir selections.
Chapter 1, Teaching the ABCs, gives tech n iqu es, ex am p les, and instruc­
tions a b o u t w h y cogn ition s are im p o rta n t a n d h o w th e y cau se e m o ­
tional and b eh a v io ra l problem s. U nd erstand ing this is crucial, b eca u se
m ost clients c o m e into co u n selin g with th e b e lie f th at th eir p ro b lem s
are caused b y a lm ost a n y v ariab le o th e r than th eir th ou ghts. It is n e c ­
essary to sh ow clients th at th eir cogn ition s are relevan t to th eir p ro b ­
lems.
Chapter 2, Finding the Beliefs, is also crucial for all later tech n iq u es. Here
we g o into great detail a b o u t h ow to find specific co g n itio n s th a t m ay
b e associated with a client's problem s. Ten different types o f c o g n i­
tions are presented and the m e th o d s to identify th em are described.
Chapter 3, Groups o f Beliefs, discusses h ow to d ev elo p a m a ste r list o f
client cognitions, h ow to trace th e m in term s o f life th em e s, a n d h ow
to develop a cognitive m a p o f th e co re beliefs th a t n ee d to b e
addressed to lessen th e client's em o tio n a l an d b eh a v io ra l problem s.
If therapists correctly acco m p lish th e proced ures m e n tio n e d in the
first th re e chapters, th ey will h a v e the fo u n d a tio n for th e rest o f the
therapy. If the client accepts, at least in part, th a t co g n itio n s are rele­
vant, th e therapist can develop a list o f the m ost im p o rta n t cognitions,
and i f th e client un derstand s h ow th o u g h ts are related, th e n th e th er­
apist is prepared to m o v e to th e last step o f co g n itiv e th erap y — h ow
to c h a n g e th e client's beliefs.
Preface xiii

Chapter 4, 5, and 6, Countering Techniques, cover cognitive c h a n g e tech­

niques. T h e th re e ch ap ters discuss chan gin g th e clients' internal lan ­
guage. Each ch ap ter presents a different c o u n te rin g techniqu e. Chapter
4, H ard Countering, discusses h ow to teach forceful disputing and ch a l­
lenging. Chapter 5, Soft Countering, describes h ow to pair relaxing and
n o n ca ta stro p h iz in g e m o tio n s to c h a n g e thoughts. Chapter 6, Objective
Countering, sh ow s how to use cou n ters devoid o f intense em o tio n al
a ssociations.
Chapters 1, 8, and 9, Perceptual Shifting Techniques, cover c h an g in g clients'
overall patterns o f perception, not ju st th eir individual beliefs. These
th re e ch ap ters discuss each tech n iq u e: Basic, Transposing, and Bridging.
Chapter 10, Historical Resynthesis, describes the third type o f ch an ge
te c h n iq u e and involves reevalu ating cognitions from the past by
resyn thesizin g them . Th ese ap p roach es rem o v e th e historical routes
for m a n y o f th e client's present destructive beliefs.
Chapter 11, Practice Techniques, provides a series o f tech n iq u es to help
clients m a k e cognitive ch a n g es habitual. T hese practice m ethod s
e n a b le clients to m aster th eir n ew cognitions.
Chapter 12, Adjuncts, presents focusing, a c o m p o n e n t u nderlying all
effective cogn itiv e procedures, and offers suggestions for using cogni­
tive restructuring w ith specialized clinical p op u lation s such as seri­
ou sly m e n ta lly ill patients, drug and alcohol addicted clients, clients
w h o sa b o ta g e coun seling , and clients in crisis.
Chapter 13, Cross-cultural Cognitive Therapy, helps clients differentiate
th eir ow n attitudes from th o se tau g h t to th em b y th eir cultural refer­
e n c e groups. This process helps clients isolate w hat they b eliev e from
w h a t th e y h av e b e e n tau g h t to believe.
Chapter 14, Philosophical Underpinnings, offers a b rie f ex p lan a tio n o f
so m e o f th e p h ilosop h ical fou n d ations for cognitive restructuring
therapy.
C hapters are based o n the sa m e ou tline a n d each includes: basic
principles u n d erly in g the cogn itive techniqu e, the specific steps to
im p le m e n t it, real ex am p le s o f h ow it has b e e n used in clinical prac­
tice, p ro b lem s to lo o k for, and ad v ice on how to ob ta in further infor­
m atio n a b o u t th e tech niqu e.
 P reface

A c k n o w led g m en ts

I dedicate this b o o k to R ob yn Strike, th e y o u n g w o m a n I m et w h ile

living and w o rk in g in Australia. H er w arm c o m p a n io n s h ip e n a b le d
me to w rite this b o o k . Her n a m e is now' R ob yn Strike M e M ullin.
1 also wish to th an k Terri Klein for p olish in g th e m a n u sc rip t and
Susan M unro, m y ed itor at Norton, fo r h e r help. As always, 1 th a n k m y
tw o daughters, Linda and M ichele, for th eir en co u ra g em en t.
T h e NEW H a n d b o ok
of
Cognitive Therapy
Techniques
 /

Introduction

I n the early 1970 s, 1 b e c a m e interested in cognitive th erap y while

c o u n s e lin g a g o ra p h o b ic clients at an east coast liberal arts college. The
case o f o n e o f th e first clients I saw after finishing grad u ate school
provides a fram e o f reference for the tech n iq u es offered in this book.
I'll call this client "Ed." Before Ed c a m e to see me, h e had seen five
o th e r therapists b u t his p rob lem hadn't lessened. He had panic attacks,
b u t didn't kn ow w h y O n the surface h e appeared a b o v e average. He
w as bright, verbal, w ell-read , high ly educated. But constant, powerful
p an ic attacks m ad e Ed m iserable. At tim es they w ere so strong that he
had to leave w ork and spen d th e rest o f th e day in bed. His panic
attacks c o n tin u e d for m a n y years. T h ey ate away at his life, cau sin g his
h ap p in ess to deteriorate. He lost his intim ate relationships, he
accep ted jo b s w ay b e lo w his ability, and h e retreated from people
until h e en d ed up alone, hiding from the world.
Ed tried in vain to find ex p la n atio n s for his misery. As an adoles­
cent, h e co n ju re d up a new th eo ry every week. O n e w eek h e decided
h e w asn't cool en o u g h , so h e w atched Jam es Dean m ovies in search o f
a h e ro to imitate. T h e next w eek h e claim ed h e was too passive, so he
tried to act like Jo h n W ayne. O n e tim e he even b o u g h t a b o o k ab o u t
self-an aly sis and tried to dig up so m e deeply repressed memory.
A n o th e r tim e h e c o n clu d ed he w asn't spiritual enough, so he read the
Lives o f the Saints and prayed for five h ou rs a day, strain ing to b e c o m e
holy. N one o f these ap p ro a ch e s worked. He a b a n d o n e d each attempt
after a co u p le o f weeks.
His n eig h b o rs had their ow n ex p la n atio n s and loved to tell him
th eir pet theories. O n e w o m a n , w h o had studied m a cro b io tic diets,
proclaim ed , "It's all th e g re ase you 're eating, all that ju n k food. If you
 T h e N e w H andbook oe Cognitive T herapy T echniq ues

followed th e diet in this b o o k I'm reading, you w ould feel right in no

time." A n o th e r suggested that Ed learn tae kw on d o to b e c o m e m ore
m asculine. A third, th e n e ig h b o r h o o d 's a m a te u r bioch em ist, d eter­
m ined th a t Ed was hypoglycem ic.
As Ed got old er h e turn ed to th erapy to seek an ex p la n a tio n for his
panics and misery. His first therapist told him h e w'as repressing his
sexual feelings. T he panics con tin u ed , so th e therapist suggested he
m ust b e repressing aggression. W h e n th e panics still con tin u ed , th e
therapist kept se a rch in g for so m eth in g else Ed was repressing. T h e sec­
o n d therapist hyp notized Ed and gav e him s o m e p o s th y p n o tic sug­
g estion s that h e was w o rth w h ile a n d safe. Ed felt g o o d fo r a c o u p le o f
hours, b u t w h en the tran ce faded h e qu ickly regressed. T h e third
c o u n se lo r didn't offer an ex p la n a tio n ; h e ju st reflected Ed's feelings.
T he fourth gav e Ed two tapes: o n e to relax a n d o n e to b e c o m e
assertive. T he tapes end ed up ca n ce lin g each o th e r out. T h e last ther­
apist ju st handed Ed so m e m e d ic a tio n that m ad e h im feel th at h e w as
floating o n a cloud all day. His panics didn't leave; th ey ju st rattled
a rou n d inside the m ed icatio n b o x in his head.
Ed felt as m iserable as ev er w h en h e c a m e to see me, his sixth th er­
apist. I didn't know w hat was causing his p a n ic attacks either, so I
decided to e x a m in e Ed's history. Ed d escribed all th e m a jo r ev en ts that
had h a p p en ed during his ch ild h ood . He said it w as happy. His fam ily
n ev er w orried a b o u t m oney, but his paren ts didn't spoil h im and
m ad e him earn his allow ance. He did well in school, played several
sports, and had several friends. All in all, his past se e m e d m o re posi­
tive than m ost people's. W e searched carefully for so m e critical event,
s o m e key that m ight ex p lain w hat had h a p p e n e d to him . But as w e
ex a m in e d his history, w e found n o th in g r e m a rk a b le— n o u n u su a l
frustrations, n o severe tra u m atic events, no o v e rw h e lm in g d isap ­
p o in tm en ts o r sadnesses. His frustrations and e x p e rie n ces w ere typi­
cal o f m ost people.
So w h ere did his p an ic attacks originate?
Initially I th ou gh t there m ight b e s o m e Freud ian -like, u n co n scio u s
reason, or possibly so m e biological, h ere d ita ry im b alan ce. But n o n e o f
these panned out. Finally, I decid ed to take o n e last lo o k at Ed's his­
tory and search for a m o re o b v io u s exp lan ation .
Although Ed's life experiences were positive and unrem arkable, there
was som eth in g unusual a b o u t Ed's to n e o f voice w h en h e described
certain events. I decided to p ro b e in to the history again, focu sing this
tim e o n Ed's beliefs, and to ask him pointed qu estions a b o u t w h at he
thought o f the event, rather than ju st ab o u t w h at had happened.
Ed paid a tten tio n to tw o ev en ts in his past: the tim e h e felt rejected
Introduction ___________________ __________________
/

in g rad e sch o o l; an d th e tim e his first girlfriend left him for a n o th er

m an. I h e follow ing is a recreation o f th e session, based o n m y case
notes.

S ession 1
ED: So, w h en I w en t to g rad e school so m e o f th e kids didn't like
m e m uch. I didn't seem to fit in.

M y usual resp o n se to this typ e o f statem en t was "That m ust have

hurt," or s o m e o th e r em p a th etic co m m u n icatio n . But this time, since
w e h ad b e e n over th e s a m e th in g so m a n y times, I decided to try
so m e th in g different.

THERAPIST: So w h at if they didn't like you ? W h y was that so ter­

rible?

I had th ou gh t this way for weeks, b u t m y grad u ate sch o o l training

a b o u t n e v e r challen g in g clients directly m ad e m e reluctant to say it.
Becau se the official tech n iqu es w ere sim p ly not working, I decided
so m e th in g different was called for.

ED: So w hat! You m u st b e kidding! It's terrible for a kid not to fit in.

Sin ce I had a b a n d o n e d th e e m p a th y approach, I decided to g o all the

way.

THERAPIST: W hy?
ED: You are su p p osed to b e the psychologist. C om e on! W h a t are
you talking a b o u t? Kids need others to like them.
THERAPIST: So you say. But what's so terrible a b o u t th em not lik­
ing you ? Did th e y b eat you up, or throw stones at you, o r what?
ED: No, o f cou rse not. I ju st w asn't liked as m uch as m ost o f the
o th e r kids.
THERAPIST: Okay. Sure, it m ay h a v e b e e n unpleasant, but you said
you had so m e o th e r friends, so w hat did it really m atter that you
w eren 't su p e r p o p u la r with ev erybody?
ED: B ecau se it m e a n t that I was different from the o th e r boys.
THERAPIST: E xcu se m e! How d o you th in k you w e re different?
ED: I felt like I m u st b e so m e kind o f weirdo, or a nerd o r so m e ­
thing.
THERAPIST: Just a m o m en t. You have told m e for several sessions
that you felt different from th e o th e r boys. Okay, m a y b e you
were. But n ow you im ply that this difference was bad. You sug­
gest th a t th ere was so m eth in g w ron g w ith you for b e in g differ­
en t— th at the difference proves you w ere inferior in so m e way.
 Th e N e w H andbook oe Cognitive T herapy T echniques

W h y ? W h y could n't y o u r dtfference indicate you w e re superior?

ED: Well, if I was better, then I would h av e b e e n popular. Right?
THERAPIST: W rong! Kids reject a n y b o d y w h o is different. T hey
don't differentiate b etw e en s o m e o n e w h o is different b e c a u s e h e
is su p erio r o r different b e c a u s e h e is inferior. T h e m ost p o p u la r
person in school is th e o n e w h o fits in th e best. A M ozart o r Ein­
stein w ould b e rejected as m u c h as a n o -h o p e r. M a y b e m ore,
b e c a u s e th e o th e r kids would b e envious.
ED: I'm n o Einstein o r M ozart!
THERAPIST: No. However, you d o n 't h a v e to b e h u gely different to
b e rejected. T he pressure to co n fo rm in a d o lesc en c e is so p o w er­
ful that peers will detect ev en sm all differences an d attack kids
w h o fail to su bm it to th e will o f th e a d o lescen t su b cu ltu re. A d o­
lescent grou ps m a y pride them selves o n not c o n fo rm in g to the
adult world. But inside th e g ro u p itself, ad olescen ts are very c o n ­
form ing. No h u m a n association acts m o re rigidly o r treats n o n ­
con form ists m o re intolerantly th a n an a d o lescen t p e e r group.
They can b e v ery cruel. T hey d o n 't tolerate b o y s o r girls w h o
don 't fit in; th ey sim p ly cast th em o u t o f th e group. T h ere are no
exceptions. T h ere is n o appeal.
ED: So how m ig h t I have b e e n different, ev en in a positive sense?
THERAPIST: You have already told me. You w ere a lot sm a rte r th a n
th e o th e r kids. W h e n they read c o m ic b o o k s, y ou read y o u r sis­
ter's college b o o k s o n astronom y, o r philosophy, o r a classic
novel, right? T heir c o m ic b o o k s b o re d you. You th o u g h t the
things y o u r peers w atched on T V o r in th e m ov ies were silly. You
liked classical m usic and read Ibsen 's plays w h en you w e re ten.
R e m e m b e r the tim e you hid a copy o f A g a m e m n o n in a c o m ic
b o o k so th a t the o th e r b o y s w o u ld n 't find out w h a t y o u w ere
reading? So, you were different all right— w ith o u t a d ou b t. That
difference w asn't the problem . You sim p ly possessed a m o re
in qu iring m ind than m ost b o y s— far more. You b ro u g h t th e
p ro b lem to life w h en you ju d ged this difference as inferior, w h en
you c o n clu d ed you lacked so m e th in g th at th e o th e r b o y s had.
Really you h ad so m eth in g th at o th e r b o y s lacked.
ED: It n ev er o ccu rred to m e that I could h a v e b e e n different in a
positive, rath er th a n a negative, way. At that tim e and sin c e then,
I alw ays to o k m y difference as a sign o f inferiority.
THERAPIST: That's th e way y o u r peers ev alu ated you, b u t d o you
ha v e to ev alu ate y o u rse lf in the s a m e way?
ED: Well no. I gu ess not.
Introduction 5
/

S ession 2
THERAPIST: So y ou were a se n io r in high sc h o o l w h en "Betsy" left
you for "M o n g o " the sailor. That's painful for all y o u n g m en. But
again, w h y did you feel so horrib le that you co n tem p lated sui­
cide? A lm ost all y o u n g m e n and w o m en are rejected at som e
tim e in th eir dating career, b u t it d o esn 't totally destroy their
lives.
ED: I discovered for th e first tim e th at no n orm al w o m a n would
ev er w a n t me.
THERAPIST: W h o a ! Stop! W h e r e does that co n clu sion c o m e from?
M a y b e sh e left b ec a u se "M on go" was b etter look in g or had m ore
money.
ED: Well, M o n g o w as a n a v y recruit th o s e days so h e didn't have
m u c h m oney, a n d h e w as o n e o f th e ugliest m e n I e v e r saw,
an d . . .
THERAPIST: Okay, m a y b e sh e left y o u b ec a u se she liked m e n in
u n ifo rm — a n y m an. O r m a y b e sh e preferred "M ongo" b ein g o n a
ship all th e tim e b e c a u s e th en h e w ouldn't b e around to b o th e r
her; or m a y b e h e had a hair)' wart o n his left ear, and sh e loved
hair)' warts. W h o know s? But g o o d heavens, Ed, w h ere did you
c o m e u p with th e co n clu sion that since s h e didn't w an t you, no
w o m a n ev er would?
ED: I don 't know ; it's ju st the way I felt.
THERAPIST: No, n ot felt . . . thought! It's ju st the way you thought.

W e review ed th e o th e r ev en ts in Ed's history and c a m e to the sam e

co n clu sion . His ex p erien ces w eren 't special, but his interpretations
were. He exaggerated, catastrophized, distorted, and twisted alm ost
ev ery m a jo r ev en t that had h ap p en ed to him. It b e c a m e clear that his
p ro b lem was n ot com p licated or esoteric— it was really qu ite simple.
His th in k in g w as twisted. Ed's p rob lem wasn't his u n con scious, biol­
ogy, diet, early upbringing, o r a n y th in g else; it was his attitude.
So w e decided to w ork o n c h a n g in g his th ou g h ts an d to forget
a b o u t th e rest. Ed improved, b u t not as rem ark ably as is usually
d escrib ed in b o o k s like this. For instance, h e didn't get up at th e end
o f th e session a n d say, "G od bless you, doctor. I am cured, cured!"
Instead h e fought th e concept, a n d kept g o in g b a ck to the "I stink" sce­
nario. Gradually, however, and with sm all steps, he did change. He
started to focu s on his th ou g h ts rath er than the events. And his panic
attacks lessened b o th in fre q u e n c y an d intensity.
O ccasionally, I get a card from him. He says h e gets a panic attack
 T h e N e w H andbook oe Cognitive T herapy T echniq ues

o n ly ever)' six m o n th s o r so and th at it is a flash panic (an alarm reac

tion for o n ly tw o or three seconds). He tells him self, "Sa m e old
garbage," and it goes away.
W h ile I w as co u n selin g Ed and o th e r clients like him , o th e r col­
leagues were c o m in g to the sa m e con clu sion s. W e started to read the
theories a n d te c h n iq u e s o f c o g n itiv e -se m a n tic therapists, particularly
th e w orks o f A lbert Ellis an d A aron Beck. T ogeth er w e d ev elo p ed ou r
ow n b ran d o f cognitive therapy. This n ew th erap y started to grow, as
o th e r psychologists had sim ilar ex p erien ces w'ith clients. Today, m a n y
therapists sp end m ost o f their sessions w o rk in g w ith clients' beliefs.
E ncou nters with th o u sa n d s o f clients like Ed h av e ta u g h t m e
this truth: I f we change our thoughts, we change ourselves.
 /

ONE

Teaching the ABCs

C thoughts. Em otions, behavior, and the

OGNFTiVH t h e r a p y f o c u s e s o n
e n v ir o n m e n t are all considered im portant, but the distinguishing fea­
ture o f cogn itiv e therapy is its co n ce n tra tio n o n th e client's beliefs,
attitudes, and cognitions.
T h e first step in a n y cognitive therapy is to teach clients the im p o r­
ta n c e o f thou ghts. Therapists m u st sh ow clients th a t beliefs, philoso­
phies, a n d s c h e m a ta can ca u se powerful em o tio n s and behaviors, and
th a t to red uce o r elim in a te n egative em otion s, clients m ust change
th eir beliefs. This is not a casu al process; therapists need to use a sys­
tem a tic m e th o d to explain th ese principles.
Before clients can e m p lo y cogn itive tech n iq u es effectively, they
m u st b e c o n v in c e d that their beliefs are co n n ected to th eir problems.
Initially, m ost clients don 't th in k so. T h ey m ay b lam e genetics, parental
m istreatm ent, tra u m a tic c h ild h o o d experiences, b ad luck, the hostile
in ten t o f others, an ill-form ed society, or an insensitive, in co m p e te n t
g o v ern m e n t. T hey accu se e v ery b o d y a n d everyth ing— except their
ow n co g n itiv e processing— for their em o tio n al pain.
T h e reason for th eir o m ission is evident. T heir thou gh ts o c cu r so
rapidly and seem so ethereal that m a n y clients don 't notice that they
are th in k in g a n y th in g at all. All th ey perceive is the en v iro n m en tal
trigger (w hich is ob jective, con crete, an d readily discernible) and the
e m o tio n a l resp o n se (w hich is p alpable and strongly felt). Transient,
n e b u lo u s th o u g h ts are u su ally ignored in the process.
It can take m u ch co n v in c in g for clients to see that th e faint little
o ic e they h e a r inside th eir heads m a y b e th e culprit, but this c o n ­
4 f * vin
. cin g m u st take place if clients are to co o p e ra te w ith cognitive th e r-
apy.
 T h e N e w H andbook qe Co g nitive T h er a py T k h n l o u e s

Tea c h in g t h e B a s ic Fo r m u la

Principles

A lth ou gh you can tea ch clients th e c o r e co n ce p ts o f co g n itiv e th er­

apy by u sing several m e th o d s, o n e o f the qu ickest a n d m o st direct is
to reserve the first cognitive session for instruction. T he first session is
usually the m ost effective tim e to present th e key form u las an d b asic
vo ca b u lary to th e client. A rrange an individual tu to rin g session or run
a g ro u p class w h en you h av e several b e g in n in g clients.

M eth od
1. If possible, d ev o te th e en tire session to th e topic. Teach clients that
there are tw o contrastin g w ays to explain w h y p e o p le feel e m o tio n s
and w h y p eople act in certain ways.
2. Present th e old er theory' that em o tio n a l and b e h a v io ra l resp onses
are caused b y s o m e th in g in the en v iro n m en t. M o st clients b e lie v e
this th eo ry is correct.
3. Next, explain th e new th eo ry that thoughts a b o u t things, n o t the
things them selves, elicit feelings.
4. Provide the client w ith a series o f ex a m p le s that c o m p a re an d c o n ­
trast the two theories. Sh ow th at th e sam e e n v ir o n m e n ta l situ ation
can b e interpreted in several different ways, a n d th a t it is th e inter­
pretation, rath er t h a n th e situation, th a t is m ost im portant.

T he F o rm u la
This is a typical first session script th a t I h a v e u sed w ith m a n y
clients. A lthou gh it ap p ears to b e a m o n o lo g u e, it is actu ally a n inter­
active dialogue in w h ic h the therapist and client are co n sta n tly ch eck ­
ing b a ck and forth w hile each co n ce p t is b e in g explained. I p rov id e a
w ritten version o f this to clients at th e e n d o f th e first session.

To solve y o u r p rob lem s y ou m u s t kn ow th e cau se o f them . This

sou n d s so ob v iou s that it m ay not seem w orth m e n tio n in g , but
m an y p eople ignore th e o b v io u s and try to discov er c au ses in a
h elter-sk elter way, u n til b y luck th ey stu m b le across an answer,
or m ore likely, th ey collapse from e x h a u stio n and c o n c lu d e that
th e p rob lem is unsolvable.
E m o tio n al p rob lem s are th e s a m e as o th e r kinds o f problem s.
If you don 't correctly identify the source, y o u will w aste effort
w o rk in g o n fixing things th at w o n 't c h a n g e h ow y ou feel.
Teaching the ABCs
9
/

But h ow d o you find th e cause?

T h e fields o f psycholog)' a n d psychiatry have so m a n y differ­
en t th eories a b o u t th e causes o f various em o tio n a l p rob lem s that
it is easy to get confused. To clear things up, let's start with two
sim p le form ulas. Learning a n d m e m o riz in g them now will save
y ou m u c h tim e and effort later on.

Old Formula

A -------------------------------------- ► t
(Draw this fo r your client during the session.)

• Each letter stands for a different thing.

• A stand s fo r an activatin g event: the situation you are in, a trig­
g e r in th e e n v iro n m e n t, a stim ulus, a n y th in g th at starts o ff the
w h o le process o f reacting.
• C stand s for eith er y o u r em o tio n s or y o u r behavior. Cs are the
c o n se q u e n c e s o f A. T hey can b e a feeling or an action.

The old th e o ry asserts that As cause Cs— that situations in

y o u r e n v ir o n m e n t cau se feelings inside you an d cause you to act
in certain ways.
To see h ow this works, picture this.
Im ag in e o n e Su n d ay afternoon you are sitting in you r chair
reading th e p ap e r w h en su dd en ly you start feeling anxious. The
fear is strong, seem s real, and it b o th ers you. You know the C
im m ediately. You feel it. Your heart is b eatin g faster, you r breath ­
ing is rapid and forced, and you feel hot and are perspiring. You
hav e a desire to get up and m ov e around, or ev en better, to run.
It's hard to ju st sit there in the chair b u t there's n o place to run
an d n o th in g to ru n from. This is th e C in o u r form ula— fear. O f
c o u r s e Cs c a n b e a n y e m o tio n — anger, sad ness, panic,
frustration— b u t for o u r ex a m p le let us say you are feeling anx­
ious.
The q u e stio n th at w ould p rob ab ly leap in to y o u r m in d this
S u n d ay a fte rn o o n is, "W h y? W h y am I su dd en ly feeling scared
a b o u t som ething, a n d w'hat a m I scared about?"
The old form u la offers an answer. It is y o u r A— the situation
you are in. It's w h a t a sou n d v id eo cam era would record if it
w ere v iew in g y o u r situ ation with n o in terpretation and no feel­
ing. T h e c a m era w ould o n ly record the sights and so u n d s that
w e re occu rrin g w h ile you w ere sitting in y o u r chair. Was the tel-
 T h e N e w H andbook oe Co g nitive T h era e * .T echniq ues

evision or radio on ? W h a t was sh ow in g? W ere you read in g the

paper? W h a t were y o u reading? W ere o th e r p e o p le in th e ro o m
and, if so, w ere they talking or lo o k in g at y o u ? W h e r e you eat­
ing or drinking so m eth in g ? W h a t w ere th e so u n d s ou tside? W ere
you lo o k in g at so m e th in g o r staring o ff into space? All th ese and
m ore are the As.
Now accord ing to this old form ula, you w ould lo o k at y o u r As
to see w h at is ca u sin g y o u r fear. T he old theory' suggests that
so m e A caused y o u r fear, and that if you lo o k v ery carefully you
m a y b e ab le to find th e A. O n c e you do, you o n ly n e e d to
rem ove th e offending A and y o u r fear shou ld dissolve.
This A -c a u se s -C th e o ry is so p o p u la r th a t w e h e a r it all th e
time. How m a n y tim es h a v e y o u heard p e o p le say, "You really
m ad e m e angry," "h e got m e upset," or "the new s really depressed
me"? All these statem en ts im ply th at s o m e ou tsid e As c a u sed us
to feel so m e inside Cs. T he idea is so u niversal th a t it seem s like
c o m m o n sense. But is it true?
No! O utside things exert little pow er o v e r us. O u r senses m a k e
us aw are o f th e ou tsid e world. If w e close o u r eyes or co v e r ou r
ears th e outside world disappears and its effect o n us is m inim al.
If w e can't detect an o b je ct w ith o n e o f o u r senses, th e o b je ct
can 't m a k e us lau gh or cry, run away, or sing or dance. O u tside
things h a v e n o m agical pow ers— th ey c a n ’t sn e a k inside o u r
head s and create o u r feelings. T h e sim p ly sit in sen sor)' d ark n ess
w aiting to b e o b serv ed b y us.
The correct form u la is w hat follows. It is sim p le and has b e e n
stated m a n y tim es before, b u t it is so essential to o u r u n d e r­
standing o f ou rselves th a t it is w o rth m em orizing. It w as created
by o n e o f th e w-orld's m ost fa m o u s psychologists— A lbert Ellis.
O thers have tried to im p ro v e u p o n it, b u t it is still o n e of th e b est
ways to explain th e key ston e o f cognitive therapy.

The n ew form ula is:

A --------------------- ► B --------------------- ► C

(Draw this fo r your client.)

As you can see, w e h a v e added a n add ition al letter: B. It stands

for o u r beliefs a b o u t the situation, and th e thou ghts, im ages,
im aginations, perceptions, con clu sion s, a n d in terp retation s that
Teaching the ABCs
/

w e tell ou rselves a b o u t A. Mostly, B stands for o u r b ra in — how

o u r b rain takes th e raw in form ation a b o u t th e As and m olds this
raw data into patterns, schem ata, them es, and stories.
A lm ost all o f y o u r e m o tio n s and b e h a v io r can b e understood
b y this n ew form ula. So instead o f sim p ly look ing at y o u r As,
lo o k at w h a t you are telling y o u rse lf ab o u t them.

P ractical E x am p les
In the first session w e often g o over th e follow ing ex am p les o n e at
a tim e until o u r clients understan d the principles.

E x a m p le 1
A = Bill's b o ss called him into his office and criticized him for tu rn ­
ing in a rep ort late.
B = Bill told h im s e lf that th e criticism was u nfair b ec a u se his secre­
tary h ad n 't typed th e report in time.
C = Bill felt angry.

W e tell clients, "You m ay th in k th e boss's criticism caused Bill's

anger, b u t in truth it's w hat Bill b elieved a b o u t th e criticism that
counts. Had h e th ou gh t the criticism valid, h e m a y h av e felt guilty or
w orried, b u t a n g e r was felt o n ly w h en his b ra in fabricated the abstrac­
tion that the criticism was unfair."

E x a m p le 2
A = Barbara look ed at her b o d y in th e mirror.
B = S h e th ou gh t sh e look ed fat.
C = S h e felt depressed.

S o m e w ould th in k that the visual im pact o f seeing a fat b o d y is the

culprit. W h o w ould n't b e upset?
M a n y people. Barbara had to first accept th a t th ere is a n ideal
fem ale w eigh t (a cu ltu ral standard that co n stan tly changes), and she
m u st h av e believed that sh e had an obligation to b e this weight. The
origin o f this se n se o f obligation is a mystery.
Sh e m u st also h a v e co n clu d ed th at sh e crossed an im aginary line
into w h at s h e arbitrarily b eliev es is an u n a ccep ta b le weight, and she
need ed to tell h erself it's terrible to b e o v er this line. T he effect o f h er
reflection in th e m irror pales in co m p a riso n to her h u ge m ental cre­
ations. H er b rain causes h e r depression, not h e r weight.
 The N ew H andbook or Cognitive Therapy Techniques

E x a m p le 3
A = Jo h n felt a pain in his sto m ach
B = He th o u g h t it m ight b e sto m ach cancer.
C = He had a flash o f panic.

Even s o m e th in g as b a sic as pain is in terpreted b y o u r b ra in s (Free­

m a n & Eimer, 1998). If y o u r m u scles are sore after a h e a v y w orkout,
you m ay ju d g e th e p ain as a sign that y o u r w o rk o u t w as successful.
T he pain o f ch ildbirth m ay b e far greater than th e pain o f disease, b u t
th e latter is far m ore o n e ro u s th a n th e fo rm e r b e c a u s e th e b ra in inter
prets th e tw o pains in qu ite different w ays— o n e b rin g s forth life; the
o th e r m a y destroy it.
In these three exam ples, w e explain to o u r clients that th e A
form ula is the key to the causes o f their em otion s. W h e n th e y feel an
u npleasant em o tio n and w an t to kn ow w h a t causes it, th ey can u se the
form ula to find out. The form ula can ultim ately help th em to ch a n g e
the upsetting em otio n s that cause o n g o in g d isruption in their lives.

C om m en t
T h ere are n u m e ro u s altern ative form u las to Ellis's A -B -C form ula,
m a n y o f w h ich are m o re com plicated. For exam p le, Teasdale and
Barnard's interactin g cogn itiv e su b sy stem s (ICS) provide a c o m p r e ­
h en siv e co n ce p tu al fra m ew o rk (Teasdale, 1993, 1996; Teasdale &
Barnard, 1993). A aron Beck (1996), M a h o n e y (1993a) an d ev en Ellis
him self (Ellis, 1988a, 1995, 1996) h a v e ex ten d e d th e form ula.
I h av e attem p ted to use all o f th ese form u las w ith m y clients, b u t 1
ha v e fou nd th a t alm ost all clients u nderstand, rem em b er, an d u se the
sim p le A -B -C fo rm u la b e tte r th a n a n y o f th e m o re c o m p licated ones.
It is not essential th at clients b e c o n v in c e d a b o u t th e efficacy o f th e
A_B-C theory at this early p oint in counselin g . In fact, m o st clients will
b e skeptical. Fu rtherm ore, they m ay not en tirely u n d e rsta n d it. In cog­
nitive restructuring therapy, a direct ch a llen g e o f clients' th eories early
on is avoided. However, it is critical to se cu re a n a g re e m e n t t h a t th e
A -B -C view m ay h av e s o m e m erit and that it is rea so n a b le to co n sid er
it further. To help p ersu ad e the clients in th e first few sessions, give A -
B -C ex a m p le s taken from o th e r p eop le's situations, not fr o m the
client's o w n life. This way, clients don 't h av e to defend th eir o w n th e­
ory, an d th ey can tacitly jo in y o u in se ein g th e m istakes o th ers h av e
m ad e in their thinking. T hese ex am p le s c a n pave th e w ay fo r e s ta b ­
lishing th e truth b e h in d the»theory.
After the first session, w e give th e h o m e w o r k a ssig n m e n t o n page
13 to o u r clients.
Teaching the ABfs
/

HOMEWORK
(Hand in at the beginning of Session #2)

NAME

ASSIGN M EN T I. Study pages 1-7 in Talk Sense to Yourself (Me Mullin

& Casey, 1975).

A SSIGN M EN T 2. Read chapters 1 and 2 from A G uide to Rational Liv­

in g (Ellis & Harper, 1998).

ASSIGNM ENT 3. The following examples describe six A-B-C situations,

but the Bs are not present. You are to guess w hat thought (B) must
be included to connect the situation (A) with the emotion (C). Identify
the (A) and (C) for each of the following, and write in the (B).

1. Alfred's boss criticized him for coming to work too late. Alfred
then felt depressed.
2. Mary came to tw o therapy sessions and quit because she thought
it wasn't working.
3. Susi had a stomach pain. Then she started to feel scared.
4. Jo e was caught in a speed trap and got very angry.
5. Ja n e was embarrassed w hen her friends saw her crying at a
romantic movie.
6. Fritz got violently angry w hen a clerk asked for identification
w hile he was cashing a check.

A SSIGN M EN T 4. Write five examples from your ow n life where your

thoughts (B) caused you painful emotions (C). Describe these exam­
ples in terms of A-B-C.

1. A.
B.
C.
2. A.
B.
C.
3. A.
B.
C.
4. A.
B.
C.
5. A.
B.
C.
 T h f N f w H andbo o k of Co c n itivl T herapy T echniq ues

F u rther In fo r m a tio n
S o m e o f th e ex am p le s an d th e h o m e w o r k a ssig n m e n t ev o lv ed fro m
m y earlier w o rk s (Casey & M e M ullin, 1976, 1985; M e M u llm & Casey,

1975)
D o n a ld M e ic h e n b a u m is o n e o f th e m a jo r c o n trib u to rs to cogn itiv e
therapy. He is th e fo u n d e r o f co g n itiv e b e h a v io r m o d ific a tio n
(M eich en b au m , 1977, 1993) a n d cogn itiv e stress in o c u la tio n train in g
(M e ich e n b a u m , 1985) a n d has m o s t re c e n tly specialized m p o s ttr a u -
m atic stress disorders (M e ich e n b a u m , 1994). H e em p h a sizes the
im p o rta n ce o f prov id in g clients w ith a n early, clear, distinct fra m e ­
w o rk fo r therapy. He suggests th at this co n ce p tu a liz a tio n a n d stru ctu re
play a n im p o rta n t role in h elp in g th e clien t to u n d ersta n d th e c h a n g e
process, and shou ld precede a n y specific tr e a tm e n t jn te jv e n tm n s . S ee
M e ic h e n b a u m (1975, 1995), M e ic h e n b a u m an d D e ffe n b a ch er (1988),
M e ic h e n b a u m an d G en est (1983), M e ic h e n b a u m an d Turk (198/).

P r o v id in g Ev id e n c e th at B e l ie f s
P r o d u c e E m o t io n s

Principles

After the therapist presents the initial fo rm u la s a n d s o m e b r ie f

ex am p les in the first session, th e hard w o rk begin s. It takes m o re than
form ulas or lectures to p ersu ad e clients a b o u t the p o w er o f cog n ition s;
therapists need to provide proof. M o st clients e n te r c o u n s e lin g with
such strongly h eld o p p o sin g view s th a t it requires m o re th a n the
a u th o rity o f th e therapist to c o n v in c e t h e m o f th e k e y princip le of
cognitive theory. 1 h av e found th e follow ing exercises help fu l in secu r­
ing th e client's co o p eratio n .

M eth o d 1. Create a n E m o tio n Now

Therapists can sh ow their clients h o w th eir beliefs, n o t th eir e n v i­
ronm ents, create particu lar em otio n s. T h e th erap ist n eeds to d e m o n ­
strate h ow clients can m a k e th em selv es feel happy, not b y c h an g in g
a n y th in g in th eir su rroun dings, ch ild h ood , o r biochem istry, b u t on ly
b y c h a n g in g w h a t they think.
To d o this, give a c o m p le te descrip tion o f a n y sc e n e th a t has sev­
eral sensu al anchors. T he m o re senses the client can use w h ile im a g ­
ining th e sc e n e the better. For o b v io u s reason s th e scen e sh o u ld b e
 Teaching the ABCs

p le a san t rath er th an aversive. You can create a n y scen e you wish but
th e follow ing is a g o o d exam ple. Tell y o u r client to im ag in e this scene
as v iv idly as possible.

Im a g in e for a m o m e n t that you are w alk in g alon g a tropical

b each . It's th e m iddle o f s u m m e r and v ery warm . It's late in the
a ftern oo n . T he sun has not yet b eg u n to set, but it's getting low
in th e h o rizon . You feel the cool, h ard -p ack ed sand b e n e a th you r
feet. You h e a r th e cry o f sea gulls and the roar o f o c e a n waves in
th e distance. You can sm ell and taste the salt in the air. As you
c o n tin u e to walk, th e sky turns gold and am ber. There is an after­
glow o f c rim so n glistenin g a ro u n d the p alm trees. T h e sun is
b e g in n in g to set into the ocean. The sky tu rn s blu e and tu rq u oise
and en v elo p s you in a deep purple twilight. A cool b reeze com es
off th e ocean. You lie dow n o n a sand d u n e an d look up at the
n igh t s k y It s a b rillian t starry night. You feel su rrou n d ed by the
cosm os. A d eep sen se o f calm and peace overtakes you. You feel
at o n e w ith th e universe. (Adapted from Kroger & Fezler, 1976)

Explain to y o u r clients that if th ey felt calm w hile y ou read this to

th em , it is b ec a u se th eir im ag ination created th e calm. Their b io c h e m ­
istry, u n co n scio u s, present en v iro n m en t, or early exp eriences w ere the
s a m e b e fo r e im ag in in g this sc e n e as during. O n ly their thoughts
changed.
If h e a rin g th e passage didn't p ro d u ce a sen se o f calm, this is also
d u e to th eir im ag ination and w h at t h e y said to them selves. W hile
h earing th e passage, "I am w alking on a tropical beach," instead o f
th in k in g a b o u t the b each , clients m ight have thou gh t, "No, I'm not! I
a m really sitting at h o m e in a chair." O r w h ile reading, "It's in the mid­
dle o f s u m m e r and v ery warm," they m ay have told them selves, "Non­
sense, it's freezing cold outside."
T h e sc e n e d o esn 't crea te their feelings, their thou gh ts do. W hat they
h eard d o esn 't m atter— o n ly w h a t they thought. T heir th o u g h ts could
h a v e created a n y em o tio n th ey desired. They could h av e created an ger
if th e y thought, "Last tim e I w alked o n a b e a c h I was with Fifi b efore
s h e left m e for that b u m , Bruno." O r fear: "A cool b reeze co m es o ff the
o c e a n . . . b u t then the p o iso n o u s jellyfish start creep ing o n to the
shore, dragging their slim y bod ies b e h in d . T h ey en circle me, waving
th eir rancid tentacles at m y legs, grabbing, grasping for me. I run but
can't escape."
To crea te a n y em otio n , all th ey had to d o was focus on a th ou gh t
to p ro d u ce it. Explain this to y o u r clients, and say, "It's not th e words,
 Tut. N l w H andbo o k qe Co g nitive T h erapy T echniq ues

th e en v iro n m en t, y o u r early c h ild h o o d ex p erien ces, o r y o u r b . o -

genetic m ak eu p th a t creates th ese feelings. Rather, it's th e picture y o u r
b ra in paints. You are the artist. Your e m o tio n s are y o u r o w n creations.

M eth o d 2. I m a g in e C han gin g A n o th er Person's Bs

A different typ e o f scen e m a y c o n v in c e o th e r clients a b o u t h ow
m ig h ty their th o u g h ts are. T he follow ing story presents a h y p o th etical
person called Fred. Therapists can e ith e r tell this story o r crea te o n e o f
their own.

Im a g in e that y ou see a m a n n a m e d Fred w alking d o w n a road.

He is n o rm a l and average in every way— not ex cep tion al, not
in san e, n o m o re n eu ro tic th a n a n y o n e else. Fie is a sa le sm a n in
a lo cal d ep artm en t store an d has a wife and tw o kids. O n T hu rs­
days h e b ow ls with his friends and o n Saturdays co a ch e s little
leag u e football. S o m etim e s h e drinks to o m u c h w h e n h e g o e s to
parties with his n eig h b o rs a n d starts argu in g to o lou d ly a b o u t
so m e political issue, b u t h e d o e sn 't drin k m u c h usually, an d g e n ­
erally is a rath er m ellow guy. His se x life w ith his w ife is g oo d ,
not as exciting as in th e early days, b u t his wife se em s content.
He is a g o o d parent, sp end s m o re tim e w ith his kids th a n m ost
fathers do, corrects th em w h e n th ey are w ro n g an d co m fo rts
them w h en they are sick. He is rea so n a b ly popular. He has the
kn ack o f getting alon g w ith different kinds o f p eople— his fellow
salesm en at w ork, th e janitor, his b o w lin g friends, his neighbors.
Now let's su ppose w e do s o m e th in g to Fred. Im a g in e th at w e
have figured o u t th e exact ch em ical c o m p o n e n t o f a belief. By
this I m e a n that w e've fo u n d th e c h e m ic a l c o m p o sitio n o f a
th ou g h t like "th e world is flat," and th e ch em ical c o m p o n e n t for
th e op p o site th o u g h t, "the w orld is round." (We reco g n ize that
this is pure fantasy. T h o u g h ts h av e physical rep re sen tatio n in ou r
brains, b u t th ey aren't c h em ical c o m p o u n d s. Still, follow th e fa n ­
tasy.) Now im ag in e th at w e’v.e b ro k e n dow n th o u sa n d s o f beliefs
into their ch em ical co m p o sitio n s and h av e put th em into
syringes t h a t w e could inject in to people.
Let's say w e w ant to in ject a particular th o u g h t in to Fred— o n e
thought, not a w h o le b u n c h o f th em . O n c e injected, this th o u g h t
will take root; Fred c a n n e v e r re m o v e it for as lo n g as h e lives.
W e don't d o a n y th in g else to Fred— w e ju st inject h im w ith this
o n e thou ght. *
Teaching the ABCs 17

W e pick a th ou g h t at random , let's say a vial o f "I need everybody

to like m e in order fo r m e to be happy" a n d w e insert it into ou r tran­
quilizer g u n and wait for Fred to w alk by o u r house. Finally, o n e
Saturday afternoon as h e w alks b y w e shoot him with the thought.
If w e follow Fred, w e w o n ’t n otice any difference in him — at
least n ot fo r a while. If w e look ed very close, w e m ay see som e
little things; his gait m ay h a v e c h a n g ed a little. W h e re b efo re he
ju st sau n tered along, n ow h e seem s to b e m o re hesitant. He w or­
ries a b o u t h ow o th e r p e o p le are w alking and starts to imitate
them .
W e follow Fred for th e rest o f the day and into th e evening. It
is Saturday night, a n d h e an d his wife h av e g o n e to a n eig h b o r­
h o o d party. Fred likes th ese parties, and is usually o n e o f the
m ost p o p u la r gu ys there. But this tim e h e isn’t. He seem s nerv­
ous, h e doesn't kn ow w h o to talk to, an d stands th ere fum bling
w ith his hands. A friend asks Fred's wife if he is feeling sick. Two
o f his n eig h b o rs are h aving th eir m o n th ly arg u m e n t ab o u t gun
c o n tro l an d ask Fred w h a t he thinks. He answers, "Well th e re are
really tw o sides to every question, and w e shou ldn't ju m p to
c o n clu sio n s to o quickly." T he n eig h b o rs lo o k strangely at Fred,
w h o has n ev er acted so u nsu re o f h im self b efore; h e usually just
c o m e s out with his opinion. His n eig h b o rs sh a k e their heads and
w'alk away.
Later th a t night Fred and his wife g o to bed. He w an ts to m ake
love b u t h e is indirect and u n su re o f himself. He tells her at least
five o r six times, "You kn ow if you 're tired I understand." Sh e per­
sistently reassures h im that it will b e all right. But Fred is u n co m ­
fo rtab le m a k in g love. He keeps asking, "Is it all right for y o u ?”
a n d h e w o n d ers if h e is a g o o d lover.
The n ex t m orning, h e has difficulties at football practice. A
boy's father asks h im to play his son M erv in e m o re o ften — he
isn't a v ery g o o d player, doesn't practice, n ev er b o th e rs to learn
th e plays, and fu m b les a lot. But Fred is afraid to say no, a n d puts
o n e o f his starters (w hose fath er isn't there) on th e bench.
M e r v in e fu m b les three tim es and the team loses badly.
I f w e ju m p several years ahead, w e notice Fred has developed
o th e r problem s. He is having tro u b le in his m arriage b ec a u se he
d ev elo p ed erectile difficulties an d hasn't b e e n ab le to m a k e love
for o v e r a year. He w e n t to a therapist and told him, It s like
w atch in g m y se lf perform."
Fred also has an ulcer. He works extra hours at the store to
 T he N e w H andbook of Co g nitive T herapy T echniques

please his boss. T he football tea m got a new co a ch after th e y lost

six gam es in a row. He hasn't b e e n invited to parties for a long
time, b u t h e know s his friends are still h a v in g them . He has tried
several different types o f tranquilizers, b u t they haven't helped.
You se e w h at has h a p p e n e d — o u r little in jec tio n has c h an g ed
Fred totally. T he th o u g h t w e im planted, "I need e v e r y b o d y to like
m e to b e happy," is o n e o f the core co g n itiv e d e te rm in a n ts o f
w hat psychologists call social phobia. By in jectin g it in to Fred we
have ruined his h ap p iness— h e has b e c o m e a peop le-p leaser, a
social phobic.
It m ay seem strange th at o n e th o u g h t can cau se so m u c h m is­
ery, b u t th e th o u g h t w e in jected is p articularly d am aging. It
destroys w h at m akes Fred so u n iq u e and turns him into a social
puppet. He loses his individuality an d w an d ers a ro u n d trying to
please everybody. C u riou sly instead o f g etting p e o p le to like
him , th e th o u g h t causes th e o p p o site reaction. People lose
respect for s o m e b o d y w h o d o esn 't express his ow n o p in io n s or
w h o is afraid to take sides on an issue. T he th o u g h t m ak es Fred
act like a wimp. O th ers see th a t there is n o b o d y left in sid e b u t a
m irror reflecting w h atev er is projected o n to it.
O f course, w e don 't h av e vials o f beliefs o r an in jec tio n gun.
However, th ou g h ts can b e injected ju st as quickly, ju st as deeply,
a n d ju st as d evastatingly in less fanciful w ays that w e will
d escribe in o u r counseling.

M eth o d 3. D ream s a n d H ypn otism

D ream s also sh ow th e p ow er o f clients' thou ghts. W h e n th e client
dream s, the outside e n v ir o n m e n t is the b e d ro o m . This reality re m a in s
th e s a m e n o m atter w h a t clients are d ream ing. W h e n th ey h av e a
nightm are, th eir fear is clearly n ot c o m in g from their e n v ir o n m e n t
(their b ed roo m s); it is c o m in g from th eir dream s. If d re a m s switch,
then th e e m o tio n s p rod uced b y th e m also switch. D ream s are Bs also,
ju st like clients' thou gh ts, b u t th ey are th o u g h ts th a t clients b eget
w h en their sen ses are reduced, and th ey are focu sed o n p ro p rio ce p ­
tive rather th a n ex tro ce p tiv e stimuli.
T he successfulness o f h y p n o tic in d u ctio n reveals that th ere are few
A causes C situations. T he cortical area o f the b ra in is ev en involved
w ith processes that a p p e a r im m e d ia te an d au to m atic, like pain. T he
su b jectiv e pain ex p erien ced w h e n pricking y o u r fin g er o n a n eed le
seem s like a clear ex a m p le p f an A -C situation. A— th e n eed le—
Teaching the ABCs 19
/

directly c a u ses C— th e pain. But hyp nosis show s that even this is an
A - B - C state. If you suggest to hyp notized subjects, "Your h a n d is in
cold w a ter a n d q u ite n u m b ; y ou can feel nothing," the su b jects won't
feel th eir finger b e in g pricked. W h ile u n d er h y p n o tic analgesia, peo­
ple still feel a kind o f stim u lation, b u t they don't describe it as "pain."
M a n y su b jects d e scrib e it as a sen satio n th a t is n eith er positive nor
negative. O f course, su bjects' ability to b lo ck pain is based o n their
cap acity to accept the reality o f the hypnotist's suggestion.
H yp n otism an d d ream s show that w h a t clients im agine is m ore
im p o rta n t to th eir em o tio n a l state th a n w h a t is real. If th ey dream
th ey are in a ship sin k in g in the North Atlantic after colliding with an
iceberg, they will feel all th e terror th at th e passengers o n th e Titanic
felt, an d th e reality th a t they are lying safely in th eir bed will not
c h a n g e th ese em otio n s. If th ey im a g in e they are five years old sw ing­
ing on a swing, th e y will feel all th e exh ilaration o f flying th rou g h the
air; it d o esn 't m a tter that th ey are an adult lying o n a hypnotist's
couch . W h a t is real to us is w h at o u r b ra in says is real.

M eth o d 4. P hysical Evidence

For clients with m o re linear processing styles or with p o o r im agina­
tions, a m o re factual approach m ay b e useful. For such clients w e pres­
en t th e physiological aspects o f the A -B -C theory. W e start by show ing
a c a rto o n picture o f a brain w ith the following labels (Figure 1.1).

F ig u re i.i Cognitive and emotional areas o f the brain (Casey & Me Mullin,
19 7 6 , 1 9 8 5 )
20 T h e N ew H andbook of Co g nitive T iie r a i ’v .Tec h n iq u es

We also suggest th at m o re ed u cated clients read Descartes' Error by

A n ton io D am asio (1994). In his b o o k h e describes th e n eu ro lo g ica l
path o f em otion s. T he process b e g in s with o u r con sciou s, d elib era te
con sid eration o f th e A. W e first reflect on th e situ atio n; w e ju d g e th e
c o n ten t o f th e ev en t o f w h ich w e are a part. W e ev alu ate its c o n s e ­
q u en ces to ourselves and others. T hese cogn itiv e e v a lu a tio n s are rep­
resented in o u r sen sory cortexes (smell, hearing, an d vision). Next, o u r
brain takes th e se rep resen tations and co m p ares th e m to o th e r situ a­
tions o f a sim ilar ty p e th at w e h av e ex p e rie n ced b efore. T h e prefrontal
area o f o u r b ra in au to m atica lly searches fo r asso ciatio n s a n d pairings
in o u r m em ory. "Have w e b e e n in this situ ation b efo re ? Is it s o m e th in g
to w orry a b o u t? W h a t h ap p en ed th e last tim e w e faced a situ ation like
this?"
This entire process is cognitive. All o f th ese are Bs. T h o u g h th ese
cogn ition s are in stan tan eo u s (often lasting less th an a second ) and
involuntary, th e y are all occu rrin g in the co rtex and p refrontal areas
o f o u r brain. O n c e these cognitive processes are com p leted , th en and
o n ly th e n is th e b io ch em istry o f c o m p le x e m o tio n s m a d e active. A u to­
matically, these cogn itiv e co n clu sio n s (in th e prefrontal areas o f o u r
brain) signal th e e m o tio n a l areas o f o u r b ra in (the am ygdala, th e a n te ­
rior cingulate, the a u to n o m ic nerv ou s system , and th e b rain stem,
a m o n g others) to start up. It is th e n that w e "feel" a n em otio n . People
w h o have physical d a m a g e to their prefrontal lob es c a n n o t g e n era te
em otions, and th u s c a n n o t e x p e rie n ce th e en su in g feelings. P hysio­
logically, Bs are the m a jo r c o m p o n e n ts o f o u r em otions.

M eth o d 5. B est E x a m p le s fr o n t th e
Client's Own H istory
M ost clients already know the pow er o f Bs fro m th eir ow n histories.
It is helpful to rem ind th em o f w h a t th ey already know. Ask th e m to
r e m e m b e r a tim e w h en they w ere greatly b o th e r e d b y som eth ing,
som eth in g that overw h elm ed th em and upset th em b u t th a t no longer
has that pow er a n y m o re — so m eth in g th at they h av e g otten over. Ask
them to focus o n this earlier ev en t and to identify th e A a n d the C.
Have them picture the situation until it b e c o m e s clear in their minds,
then ask th em to identify the Bs. W h a t did th ey tell them selv es w h en
they got so upset? Finally, have th e m focus o n w h at th ey b eliev e today.
W hat are they telling them selves now that th ey didn't b e lie v e before?
M ost clients learn that the m ost d a m ag in g th in g a b o u t th e earlier
event was not w hat h a p p e n e d 'b u t w h at th ey said to them selv es a b o u t
leaching the ABCs. 21
/

it. T h e effects o f an ev en t m ay en d quickly, b u t their self-statem en ts at

th e tim e are far m ore long lasting; the effect o f their con clu sion s can
b e devastating, a n d m ay last a lifetime. Help y o u r client to see that it
was not th e traum a that caused their problem s, it was their B.

M eth o d 6. I f th e B ch a n g es, th e C ch an g es.

G ive y o u r clients so m e A -B exam ples. Hold th e situation (A) as a
co n sta n t, b u t v ary w h a t th ey say to them selves. Ask th em to identify
w h a t e m o tio n would b e created b y the different th ou g h ts (B). You can
d e scrib e th e ex a m p le s to y o u r clients, includ e th e m in h om ew ork
assignm ents, put th em in a pam phlet, program th em on a computer,
o r sh ow th em o n slides in grou p sessions. Here are so m e exam ples:

1. Im ag in e y o u are sitting in th e cafeteria at w ork and you see two

c o llea g u es talking in w'hispers and occa sio n a lly glan cin g in you r
direction. W h a t you feel is d e p en d en t o n w h at you tell yourself. If
y o u think, "How terribly rude th ey are talking a b o u t m e b e h in d my
back," y o u will feel angry. If you think, "They m u st have found out
a b o u t th e m istak e I m ad e yesterday o n the H u tchinso n account,"
y ou will feel guilty. If you b e lie v e th ey are p lannin g a surprise party
for y o u r b irth d a y next week, you m a y feel happy. T h e A is th e sam e
in all cases. Your Bs a lo n e p ro d u ce the different em otions.
2. This e x a m p le c o m es from Hauck (1980). Im a g in e that w hile reading
this b o o k you su d d en ly lo o k dow n and see a sn a k e coiled around
y o u r legs. Unless you like snakes you will p rob ab ly b e upset.
Im p ulses from y o u r brain send n eu ral ch em ical messages that pro­
du ce e n d o c rin e an d o th e r resp on ses in y o u r blood stream . These
signal y o u r m u scles and lim bs and cause you to have a startled
response. If s o m e o n e asks you w h y you are upset you m ay b reath ­
lessly p oint to th e snake.
T his looks like a clear A -C situation. You see the snake, A, w hich
causes you to b e c o m e afraid at C. But if so m e o n e co m es over, picks
u p th e sn a k e and show s you th a t it is a ru b b er snake, will you still
b e afraid? In m ost cases, p ro b a b ly not. W h a t is the difference? The
A is th e sam e ; y ou still see th e sn a k e lying at you r feet. T he differ­
e n c e in w h a t you feel is o n ly y o u r thought. In the first case, you
p ro b a b ly in sta n ta n eo u sly th ou g h t several things: "It is a snake. It is
real. It m a y b e poison ou s. It could h arm me." Rem em ber, although
it can take several se co n d s to read th ese thoughts, y ou could have
th o u g h t th em all in a m illisecond. In the second situation you
22 T u t N e w H andbook , of ..Cognitive T h e r a p y T echniques

thought, "It's a toy snake. T oy-snakes can't hurt me. I h a v e n o rea­

son to b e upset." Seein g th e sn ak e didn't m a k e you feel a n y th in g at
all; it's w h at you said to y o u rse lf a b o u t w h at y o u saw th a t m a d e th e
difference.
3. C onsid er th ese various Cs in resp o n se to th e s a m e A.

A = You have an a p p o in tm e n t with a close friend b u t he

is a n h o u r and a h a lf late.
C = You are afraid.

W h a t w ould you h av e to say to y o u rse lf at B to ignite y o u r fear?

B = "He has b e e n in an accident, a n d m ay b e hurt."

or,

C = You are angry.

W h at w ould you need to th in k to create this?

B = "How rude o f h im to keep m e w aitin g w ith o u t calling

me.”

or,
C = You are depressed.

W h a t w ould ca u se you to feel this?

B = "I guess he thinks so little o f m e that h e d o esn 't feel th e need

to show up on time."

T h e A is the sa m e in all the exam ples. T he o n ly v a ria b le th a t could

ca u se th e different e m o tio n s at C is w h a t y o u told y o u r s e lf at B.

M eth o d 7. Create a n E m o tio n Directly

1. Have you r clients practice shifting th eir e m o tio n s slightly b y sim ply
chan gin g th eir thoughts. Direct th em to m a k e th e m s e lv e s feel
happy, slightly sad, am used, prou d and se lf-co n fid en t, safe and
con ten t, a n d to try rapidly sw itch in g from o n e feeling to another.
This exercise shou ld b e d o n e fo r five m in u tes a day. (See ration al
em o tiv e imager)' in c h a p te r 8.)
2. Ask y o u r clients to o b serv e p eople w h o are acting in w ays th ey
co n sid er odd or u n usual, and to co n sid er w hat th o se p e o p le m ig h t
b e telling them selv es th a t m akes th e m act in th o se ways. W h a t
w ould th ey have to b eliev e*in o rd e r to b e h a v e in su ch a strange
m a n n e r them selves?
leaching the A B £ s _ 23
/

C om m en t
It w o u ld b e o v e rw h e lm in g for clients to go th ro u g h all o f the m e th ­
o d s ju st m e n tio n ed , b u t it is u sefu l for th e therapist to learn all o f
them , b e c a u s e y o u c a n n o t b e sure w h ich m e th o d will b e most per­
su asive for a particular client.
T h e b est ex a m p le s are th o se th at the client creates. These have the
a d v a n ta g e o f b e in g p erson ally significant and thus h a v e b u ilt-in per­
su asive strength. T h e therapist shou ld en co u ra g e clients to th in k o f
th eir ow n exam p les o f how Bs ca u se Cs.

F u rther In fo r m a tio n
O n e o f th e m ost efficaciou s b o o k s for relaxation images is Hypnosis
an d Behavior M odification: Im agery Conditioning (Kroger & Fezler, 1976).
See D am asio (1994) o r Gregory (1977 1987) for in form ation on brain
p h y sio lo g y fo r the lay person
C ognitive th erap y for m a n a g e m e n t o f pain has b e e n explored b y
Baker and Kirsch (1991), C ipher and Fernandez (1997), Litt (1988),
M e ic h e n b a u m a n d G enest (1983), Scott and Leonard (1978), Sternbach
(1987), a n d Turkat and A dam s (1982).
R ation al em o tiv e b e h a v io r therapy (REBT) therapists provide so m e
o f th e m ost effective analogies o f cogn itive principles th a t you can use
w ith y o u r clients. T hey are u n u sually clear and im age forming. Pay
particular atten tion to the w orks o f the REBT therapist Paul Ila u ck
(1967, 1980, 1991, 1994).
In so m e o f m y earlier b o o k s, I provide a n u m b e r o f m eta p h o rs and
im ages that therapists can use. S ee Casey an d M e M ullin (1976, 1985),
M e M u llin, Assafi, and C h a p m a n (1978), M e M u llin a n d Casey (1975),
M e M ullin, Casey, a n d Navez (1979) (in Spanish), M e M ullin and
G e h lh a a r (1990a), and Me M ullin, Gehlhaar, and Jam es (1990).

How P o w e rfu l A re E n v iro n m e n ta l F o rce s?

Principles

Despite the therapist's b est efforts in teaching the A -B -C principles,

m a n y clients still insist that certain e n v iro n m e n ta l forces (As) are so
pow erful th at they overrid e th e effects o f a n y p ercep tio n or thought.
T h e As th ey suggest as m o st pow erful are physical en v iro n m en t, early
c h ild h o o d exp erien ces, biochem istry, u n con scio u s, a n d heredity.
T h ese As are powerful, b u t as stated earlier, their ability to influ ence
 T h e N e w H andbook oi Co g nitive T h erapy T echniq ues

p eople and d o m in a te lives is Based o n how p e o p le cognitize th e m

rath er th an th e As them selves. Heredity, bioch em istry, and early child­
h o o d ex p erien ces are no different fro m o th e r A?. T h ey are triggers or
stimuli, b u t th ey don 't co n tro l a person. In o th e r words, th e y m a y
incline p eople to act, b u t th ey d o n 't m ake th em act. Stron g p red isposi­
tion created b y early ch ild h o o d exp eriences, physical con d ition , b io ­
chemistry, o r hered ity c a n o ften b e offset or m itigated b y th e client's
Bs. T he follow ing m e th o d s and ex a m p le s sh ow how.

M eth od
1. Tell the patient a b o u t s o m e o n e you kn ow w h o has c o n q u e r e d a
severe ch ild h o o d experience.
2. G ive an e x a m p le o f a person w h o se th ou g h ts and attitu d e o v er­
c a m e a severe physical handicap.

E x a m p le 1. O v e rco m in g Bad C h ild h oo d As: T h e S to ry o f

A nna
O n e o f m y first clients was a w o m a n I'll call A nna. Sh e was an old er
w o m a n w h o had entered co u n selin g for gen eral a n x iety and d ep res­
sion. Sh e had suffered th ro u g h o n e o f th e w orst c h ild h o o d ex p e ri­
en ces a n y o n e could imagine.
A nna had b e e n b o r n in a sm all Russian tow n b e fo re W orld W a r II.
W h e n the G erm an s invaded h e r village, th ey enslaved th e .tow nspeo­
ple an d forced th em to w ork for the Third Reich. Partisans livin g in the
su rrou n d in g area w ere sa b o ta g in g arm y su p p ly lines, a n d th e G er­
m an s decided to m a k e an e x a m p le o f th e village.
Early o n e ev en in g SS troops rou n d ed up e v e ry o n e in to w n — m en,
w o m en , and ch ild ren— an d m arched them to a ravine. A n n a a n d h er
m o th e r w ere dragged alon g w ith the rest. T he Nazis forced th e vil­
lagers to hu ddle in a g u lly T h ey th e n lined u p m a c h in e gu n s o n the
o u ter edge and fired. W h ile p e o p le w ere sc re a m in g an d trying to
clim b out, A nna's m o th e r pushed h e r u n d e r n e a th th e falling bodies.
The dead and dying on top o f h e r shielded A n n a from th e bullets.
All night lo n g sh e hid there. Sh e w as soak ed w ith b lo o d , a n d p e o ­
ple m o a n e d all a ro u n d her. After several hou rs, th e m o a n in g stopped.
Everyone was dead b u t Anna, an d sh e felt too terrified to leave.
T h e next m o rn in g p eople from a n e ig h b o rin g village se a rch e d for
relatives a m o n g th e slain. T h ey heard A n na w h im p e rin g a n d franti­
cally du g th ro u g h the bodies, follow ing th e sou n d o f h e r crying until
th ey u n co v ered her. T hey carVied A n na h o m e a n d gav e h e r fo o d and
Teaching the ABCs 25
/

com fort. S h e was th e o n ly su rvivo r o f th e village, and h u ndred s of

partisans spent m o n th s taking care o f her, m ov in g h e r from o n e tow n
to a n o t h e r and hiding h e r from the SS. Finally th ey arran ged to sm ug­
gle h e r o u t o f Russia th ro u g h the underground . Sh e settled in the U.S.,
w h e r e sh e lived with so m e distant relatives.
For years A nna suffered from horrible nightm ares. Friends repeat­
ed ly suggested sh e see a therapist b u t sh e resisted— at last sh e called
me.
I o b v io u sly cou ld n 't erase th e appalling ev en t that had hap p en ed
to her, b u t 1 co u ld h elp her to c h a n g e th e way s h e look ed at it. Instead
o f focu sin g o n th e exp erien ce, w e co n cen tra ted o n her beliefs, and we
search ed for a new v ie w p o in t to c o p e w ith h er a n cien t pain. We
ex a m in e d the broad, sw eep ing p rob lem s all p eople face. W e discussed
o u r deeply felt values a b o u t p h ilosoph ical a n d religious su b jects such
as life a n d death, and g o o d and evil.
After a w h ile the session s helped. Sh e would alw ays feel so m e pain,
b u t A n n a had learned to accept w h at h ad hap p en ed . This was the key.
S h e had accepted th at so m e tim e s b ad things h a p p e n to g oo d people
for n o reason. Sh e agreed th a t sh e didn't deserve it, that sh e had done
n o th in g to ca u se it, and that th ere was n o th in g sh e could have d on e
to prevent it. But m ost importantly, sh e learned to accept that m an y
tim es th e universe isn't the way sh e w ould like it to be. It can b e nasty
and painful, and it has n o obligation to b e different from w h at it is.
W h e n sh e could accept living in this kind o f universe, h e r anxiety and
d epression shriveled up, and s h e b e c a m e happier.
A nn a's story teaches us a great truth. H u m a n b ein g s h av e an am az­
ing ability to adapt. No m atter h ow bad o u r ch ild h ood or how horri­
ble o u r exp eriences, w e can rise a b o v e all o f these and free ourselves
b y c h a n g in g th e way w e lo o k at life.

E x a m p le 2. O v e r c o m in g Bad P hysical As
C on sid er this ex a m p le o f a person w h o o v e rca m e a severe physical
con d ition . T h e ev en t to o k place a few years back in the New York
m a ra th o n . T h e race had finished hours before, an d it was late in the
ev en in g . T he TV was sh o w in g interview s o f the day's winners, and
alm ost as an aside, th e ca m era p a n n e d to a live shot o f a m an w ho
was still on th e course. He was w ith o u t legs, pushing h im self o n a
board . His h a n d s were b a n d a g e d and bloody, b u t he con tin u ed to
push w ith ev ery th in g he had. He was on b a ck streets, and only a few
p e o p le were w atch in g — an old er couple, a m a n co m in g h o m e from
work, a h o m e le ss m a n sitting o n a curbside. Six or seven adolescent
 T he N ew H andbook of Co g nitive T herapy T ech n iq u es

kids, look in g like they'd b e m o t e at h o m e in a g a n g th a n w a tc h in g a

race, also look ed on.
As h e was c o m in g up the street, th e few p e o p le p resent acted
em b a rra ssed for him. Everyone b u t the adolescents, w h o ap p eared to
b e m o ck in g and tau n tin g him, look ed away, preten d in g th ey didn't
see him.
T h e m a n seem ed to ignore th em all, and kept lo o k in g straight
ahead, pushing w ith all his might. But as h e passed the p e o p le and
th ey looked at his face, th ey m u st have seen his expression, o r su d­
denly u n d erstoo d w h a t th e m an was doing, b e c a u s e a r e m a rk a b le
thing happ ened . All o f th e p e o p le w h o had b e e n ign o rin g or m o ck in g
h im started to ch eer— not ju st polite cheering, b u t sh o u tin g and
screa m in g at full volu m e, en co u rag in g him to contin ue. T h ey were
ju m p in g up and dow n, ru n n in g next to him , pleading with him to
keep trying, patting h im on th e back. T h e street kids w ere ch eerin g
lou der th a n a n y o n e else, and it w asn't p h o n y m o c k in g ch eerin g — it
w'as gu t-b u stin g , sou l-d riving, pow erful cheering.
W h y the change? W h y did th ey su d d en ly stop m o c k in g h im and
start cheering h im ? W e don 't know, b u t w e can guess. W e c a n im a g ­
ine that the spectators m a y h av e recognized th a t this m an was doing
ev eryth in g h e could ju st to finish th e race. He w a s p u ttin g ev ery effort,
every bit o f en ergy h e could m u ster to keep o n going, an d it w as this
en erg y and spirit that they u n d ersto o d an d recognized and ad m ired
and cheered. T h e m a n was still han dicapp ed, b u t his spirit rose a b o v e
it all a n d m ad e his physical im p airm en t incon seq u en tial.

C om m en t 1
O u r two ex am p les reveal that c o p in g with pow erful As (w h eth er
th ey b e tra u m a tic ch ild h o o d ev en ts or physical handicaps) un covers
an im p o rta n t principle a b o u t people. After offering th ese tw o e x a m ­
ples to o u r clients, w e o ften ex p la in th e principles b y giving th em the
handout, "W h y As Aren't Everything."
C ou n teracting th e im p o rta n c e -o f A can b e v ery th e ra p e u tic in itself,
particularly for clients w h o have had to c o p e w ith severe e n v ir o n ­
m en tal or physical h andicaps. P osttraum atic stress disord er victim s
often have to c o p e w ith feelings o f help lessness; this is cau sed b y hav­
ing b e e n ex p osed to forces b e y o n d th eir con trol. For su ch people, a
few sh ort exam p les are not sufficient to o v e rco m e th e th o u g h t th at the
As are ju st lo o powerful to b e cop ed with. Therapists m a y find it b e n -
Teaching the ABCs 27
/

H A N D O U T : W H Y As A R E N ' T E V E R Y T H I N G

Ultimately the greatest payoff for being human is not in having a

wonderful childhood, winning a race, or living a calm, tranquil life.
Nor is it based on heaps of money, fame, more pleasure than pain, or
the promised reward of a better life hereafter. The real payoff may be
in pouring all of our being into reaching a goal, whether it is winning
a race, or accepting a horrible childhood, or living through a trau­
matic event. The immature human only sees the immediate gain or
loss in each situation, but the person w h o knows the pain of life
seeks the long-term reward. The reward for Anna and the marathon
man is grander than the immediate reinforcement of the moment. It
is the ultimate payoff of using all of our energy, all of our ability, all of
our strength for one grand final push, striving for a goal until we
reach it or w e die trying. The goal is irrelevant, and reaching it is as
well; it's the striving that counts.
 D ie N ew H a n dbook qe Co g nitive T h er a py T echniq ues .

eficial to assign b o o k s that illustrate h u m a n b e in g s o v e rco m in g

adversity b y c h an g in g and e n h a n c in g th eir beliefs (see section o n fur­
th e r inform ation for so m e examples).

H om ew ork
At th e end o f the A -B -C sessions, w e give all clients the h o m e w o r k
assig n m en t o n p. 29. No m atter w h a t add ition al h o m e w o r k is
assigned, th ey c o n tin u e this h o m e w o r k th ro u g h o u t th e rest o f the
c ou n selin g

Com m ent

There is a d a n g e r th a t therapists sh ou ld b e aw are o f w'hile teaching

th e A -B -C th eo ry and th e pow er o f b elie f— s o m e clients m a y o v erd o
it. Su ggestible clients, with th e aid o f u n scru p u lo u s counselors, m edia
hype, o r wishful thinking, m ay c o m e to b e lie v e th a t h u m a n s can c o n ­
trol ev eryth in g sim p ly b y exercisin g the p ow er o f th e mind.
This h a p p en ed to John n y, an ad o lescen t client I saw years ago. He
had b e e n a m e m b e r o f a q u a si-re lig io u s cult that tau g h t o n ly o n e
principle: You can co n tro l an y th in g w ith y o u r mind.
"Virtually anything," h e reported. T he elders o f th e cult had told him
th a t h e could acq u ire ev eryth in g h e w an ted i f h e learned to co n tro l
his thoughts. He could c h a n g e th e weather, gain great w ealth, stop
wars, cu re fam ine— a n y th in g at all. All h e need ed w as to h a v e faith
and to b e lie v e that h e could.
Jo h n n y sp en t a y e a r testing the principle; h e tried to stop his ten ­
nis e lb o w from acting up, h e strove to m aterialize h am san d w iches
w h en h e was hungry. O f course, h e didn't succeed. W h e n h e w en t
b a ck to th e elders, suggesting that perh ap s they w e re w rong, they
s h o o k their heads and said h e didn't have e n o u g h faith. T h ey insisted,
"You m u st h a v e a b so lu tely no d o u b t w hatsoever. If you d o u b t ev en a
little, this u ncertainty will ob literate y o u r power." T h ey also expressed
th eir d isa p p o in tm e n t th a t h e was n ot tu rn in g o u t to b e th e typ e o f
novitiate they h ad h o p e d for.
Jo h n n y w en t o u t and tried again, this tim e ev en harder. No ham
sand w iches appeared, and h e b e c a m e p o o r e r rath er th a n richer
b e c a u s e o f all o f his d o n a tio n s to th e cult. As for his ten n is elbow, h e
had stopped noticing th e pain w h e n th e m ig ra in e h e a d a ch e s h e b e g a n
getting g ra b b e d his attention.
For two years Jo h n n y tried^ to find sufficient faith to m a k e his
thou ghts powerful enough, b u t h e n ev er su cceeded. B ecau se h e felt
Teaching the AB.Cs._ _ _ _ _ _ _
/

HOMEWORK

N a m e ____________________ _____________

If y o u wish to try to help yo u rself with the material given to y o u in

counseling, the first step is to learn to distinguish As, Bs, and Cs. In
practice, people find the C first, then the A, and lastly the B. Each
day, do the following:

1. Identify the strongest negative emotion you have had during the
last 24 hours. You may have had many, but choose the strongest.
Look for emotions such as fear, sadness, or anger. Allow yourself to
focus on the emotion. Let it emerge until you can feel it distinctly
but at a low level.
2. Next, search for the A. W h at was occurring right before you felt
the emotion? Be sure not to include any of your thoughts at this
point. An A is w h at a sound motion picture camera would pick up if
it were observing the scene. The camera wouldn't interpret w hat it
saw; it w ould simply record it.
To find the As, you may need to pinpoint the exact time that you
felt the emotion. If the time is not readily apparent, review your
activities for the last 24 hours. Begin w hen you woke up and visual­
ize in detail w h at you did. Keep reviewing the day until you first
noticed the emotion. W h en you find the correct time, review every­
thing going on around you w hen you were feeling the emotion.
W h at w ere you looking at? W hat sounds did you hear? Were there
an y smells or tastes present? Were there any internal sensations you
w ere having right before the emotion occurred, such as an upset
stomach, or an arm pain, or a feeling of dizziness?
3. Finally, find the B. W h at did you tell yourself in the situation that
caused you to feel the emotion? In most cases you will have told
yourself many things. Try to find them all. In time you will have a list
of your most common beliefs, but for n o w you will have to guess.
You will know that you've found the right belief if the thought
serves as a bridge between the A and C. If you can imagine every­
one with that belief feeling the same emotion then you are probably
correct. If someone would have had the thought but wouldn't feel
the emotion, then you haven't found the right belief.
4. Continue to d o th e a b o v e procedure. Survey your em otions for a
w eek or more. Later, w h en you feel a strong em otion, find the A-B-
C. Record w h a t you find. Over time you will discover that th e sam e
situations, beliefs, an d em otions keep show ing up. You will then be
a b le to find your patterns of thinking.
30 T h e N e w H andbook of Co g nitive T herapy T echniq ues

guilty for failing, h e sou gh t counseling . I told h im th at th e elders' ideas

were absurd. T hou ghts are indeed powerful, b u t n ot th at pow erful.
The elders h a d twisted cogn itiv e th erap y b e y o n d all recognition.
I w rote out th e follow ing resp onse for Jo h n n y a n d discussed it with
him.

Every h u m a n b e in g lives in tw o sph eres— th e inside an d th e o u t­

side. W h a t h ap p en s in o n e sp h ere cannot in flu en ce th e o th e r
unless you bu ild a bridge c o n n e c tin g the two. Your th o u g h ts are
in the inside sph ere— that is, th e y are inside y o u r body. Your
beliefs and attitudes c a n in flu en ce a n y th in g that is also o ccu rrin g
inside y o u r b o d y Since y o u r spinal cord c o n n e c ts y o u r b rain to
various b o d ily system s, y o u r th ou g h ts can b e v ery powerful.
Your th ou g h ts can prod u ce ch an g es in you r digestive sy stem and
cause stom ach p rob lem s; y o u r respirator)' system an d p ro d u ce
asthm a o r hyp erventilation; y o u r card iovascu lar system and
accelerate y o u r h eart o r b lo o d pressure; y o u r e n d o c rin e system
and secrete h o rm o n e s th at p ro d u ce panic, rage, o r despair; y o u r
defense and lym p h atic system and red u ce y o u r ab ility to w ith ­
stand disease an d infections; y o u r m u sc u la r system a n d cause
m ig rain e h ead ach es o r low b a ck pain; o r y o u r rep ro d u ctiv e sys­
tem and m a k e you arou sed o r im potent.
But you r b rain is n o t c o n n ec ted to h a m sand w iches, th e stock
market, unlim ited b a n k accounts, w e a th e r system s, or th e c o m ­
bin ed m ilitary-ind u strial c o m p le x o f nations. T h ese things are in
th e se co n d sp h ere (outside o f you) and all th e th in k in g o r w ish­
ing (inside o f you) w o n 't c h a n g e this sphere.
If you w an t to c h a n g e th e ou tsid e sph ere and m a k e a differ­
en ce o n this planet, y ou had b e st build a bridge— a bridge
b etw e en y o u r inside and y o u r outside. And y o u alread y h av e
one. It's called b e h a v io r a n d it m e an s action. It m a y take th e form
o f physical energy, speaking, or writing. U nlike th e m in d -p o w e r
drivel, y o u r m e th o d s o f affecting y o u r w orld are n o t dram atic,
exciting, o r quick, b u t they d o accom p lish results. To a ch iev e
power, you h av e to b e w illing to put aw ay m in d g a m e s an d get
dow n to so m e hard, c o n cre te work.

F u rther In fo r m a tio n
Spangler, Sim ons, M o n ro e , and T h ase (1997) fou n d th at As (negative
life events) were n ot a crucial factor in h ow well clients su cceed ed w ith
cogn itive therapy.
Teaching the ABCs 31
/

S o m e o f th e great classics in literature are b ased o n people's ability

to s u r m o u n t ov erp o w erin g forces b y ch an gin g beliefs. T he therapist
can m a k e his or her ow n selections, b u t w e are im pressed with Man's
Search f o r M eaning b y V ictor FrankI (1980) (Frankl's logo therap y is o n e o f
t h e precursors to cogn itiv e therapy) and The Diary o f Anne Irank. M an y
novels a n d stories are insp irational b eca u se they describe how
h u m a n ity can rise a b o v e th eir As.

L e a r n in g t h e Co n cepts

Principles

O n e h o u r a w eek o f ex p la in in g cognitive principles to clients is

hardly sufficient to im prove the efficacy o f cognitive therapy, espe­
cially if clients c o n tin u e to th in k in th eir form er w ays fo r the o th er 167
h o u rs o f th e week. For th e cogn itive approach to b e u nd erstoo d and
retained, clients need to practice the new typ e o f th in k in g after they
leav e y o u r office. W e have fou n d several m e th o d s effective in im prov­
ing clients' reten tion o f th e material.

M eth o d 1. Client M an u a ls
We give m a n u a ls to all clients w h o attend individual o r group ses­
sions. T h ey are very helpful— alm ost essential, in fact— in reinforcing
t h e ideas presented in th e sessions. Inform al surveys sh ow that clients
d o u b le th eir reten tion o f session m aterial w h en th ey can review it in
c o rre sp o n d in g m anuals. You may use published m an u als (Figure 1.2)
o r th o se o f o th e r therapists. You m ay find it is m ost help fu l to create
y o u r o w n m a n u a ls th a t m o re closely reflect you r ow n counselin g

W e w rote th ese m a n u a ls (in Figure 1.2) to address different client

p rob lem s. Talk Sense lo Yourself (M e M ullin & Casey, 1975) and its Span­
ish translation (Me M ullin, Casey, & Navas, 1977) addresses general
adult a n x iety a n d depression. Straight Talk to Parents was w ritten for par­
en ts h a v in g difficulty w ith their child ren (Me M ullin, Assafi, & Chap­
m an, 1978). The Lizard is a b e g in n in g m an u al that discusses alcohol
p rob lem s (M e M ullin, Gehlhaar, & Jam es, 1990). T h e fifth m an u al is
m ore ad v an ced and for addicts and alcoholics (Me M ullin & Gehlhaar,
1990a) T h ese m a n u a ls parallel o u r individual an d grou p sessions; if a
session covered m e th o d s o f c h a n g in g dam agin g beliefs, th e client >s
told to read the m an u al's section o n elim inatin g an irrational thought.
32 T h e N ew H andbook of Cognitive T h e ra py T echniq ues

All o f th e m an u als are w ritten in th e sa m e style. T hey co v e r the

m ost im p o rta n t poin ts o f each th era p e u tic session an d th ey are inter­
active in a p ro g ra m -le a rn in g fashion so th at th e clien t can practice
w hat has b e e n presented in therapy. T h ey are short (50 pages o r less)
a n d th ey in clu d e as m a n y illustrations and c a rto o n s as co u ld b e m a n ­
aged.

M eth o d 2. O utside R e a d in g s
W ith the financial lim itations presently placed o n th era p e u tic ses­
sions b y HMOs, it is essential th at clients learn as m u ch in fo rm a tio n
as they can outside o f th e cou n selin g hour. S e lf-h e lp b o o k s ca n save
v a lu a b le session tim e for b o th therapists and clients. U nlike th e m a n ­
uals, th ey don 't provide a s te p -b y -s te p ou tlin e o f in -sessio n m aterial;
th ey do provide m ore detailed in fo rm a tio n a b o u t s o m e co n ce p ts or
exercises that can b e b etter digested ou tsid e o f th e th era p e u tic hour.
B ecause o f this, therapists o ften assign b o t h th e m a n u a ls an d a c h a p ­
ter from an approp riate self-h elp b o o k fo r th e n ex t session. O th er
therapists m a y have th eir ow n favorites, b u t o v e r th e years o u r clients
have n o m in a te d th e follow ing co g n itiv e ly -o rie n te d se lf-h e lp b o o k s as
th e m ost beneficial.
Ranked first is o n e o f th e m ost p o p u la r se lf-h e lp b o o k s published.
W ritten b y A lbert Ellis and R obert Harper, th e b o o k n ow has three
editions: A Guide to R ational Living (Ellis & Harper, 1961), and its revi­
sions, A New Guide to R ational Living, 2n d Edition (1975), an d A Guide to
Rational Living, 3rd Edition (1998). R anked secon d is o n e o f th e first
b o o k s th a t explained to th e p u blic s o m e b a sic principles o f cognitive
therapy— Your Erroneous Zones (Dyer, 1995). N u m b e r 3 presents a c o m b i­
nations o f different cogn itiv e ap p ro a ch e s— Feeling Good: The N ew M ood
Therapy (Burns, 1980, 1989). N u m b e r 4 is a n ew er b o o k b y Dr. Ellis—

F ig u r e i .a C lie n t m a n u a ls
Teaching the ABCs 33
0

A FEELING How to
stubbornly
G u id e GOOD refu se to
To m ake

E
y o u rse lf
NEW MOOD
RATIONAL THERAPY m iserable

LIVING ab o u t
a n y th in g ,
yes,
DflVIDD. BURNS.M.D.
AulSx d IHJlMAIi. COflXETTXNS an ything!
AAfONlMScK.H I)

F i g u r e 1.3 M o s t p o p u la r s e lf - h e lp b o o k s

How to Stubbornly Refuse to M ake yourself M iserable about Anything, Yes, Any­
thing (Ellis, 1988a). N u m b e r 5 is a specialist b o o k for marital cou n sel­
ing th a t w as not gen erally p o p u la r but that o u r m arital therapy clients
liked— A Guide to Successful M arriage (Ellis & Harper, 1961).

M eth o d 3. M u ltim ed ia , A udio, V id eotap es, Cartoons,

a n d C om pu ter P rog ram s
W h e n tea ch in g th e A -B -C s an d o th e r aspects o f cognitive therapy,
therapists shou ld use as m a n y learning aids as possible. A client's abil­
ity to c o m p r e h e n d and retain verbal m aterial is limited, b u t if the
therapist transform s th e in fo rm a tio n into visual cues, reten tion is
increased. This section th a t y o u 're reading illustrates this principle;
instead o f sim p ly listing the b iblio g rap h ic references to manuals, self-
help b o o k s, slides, and cartoo ns, 1 have sh o w n th e actual illustrations.
W ith th e se visual cu es is it not easier to r e m e m b e r what was read?
Slides. T h e key p oin ts o f all the th erap e u tic sessions can b e put on
slides. T h e Cognitive Restructuring Therapy Package, Revised (Casey & Me
M u llin , 1976, 1985) illustrates 5 4 slides used in o u r grou p sessions.
Video an d audiotapes. O n e o f the b est sou rces for audio and vid eo­
tapes is th e A lbert Ellis Institute for R ation al Em otive B ehavior Ther­
apy, 45 E. 65th St., New York, NY 10021, (800) 5 23-4738, E-m ail:
o rd e r s@ r e b t.o r g .
T h e A m erican Psychological Association offers m a n y useful books,
films, an d tapes. See th e ir w ebsite: http://apa.org/books/.
Cartoons. You can identify the key co n ce p ts o f y o u r therapy and cap­
ture th em in su ccin ct c a rto o n s that will significantly help y o u r client
r e m e m b e r y o u r concepts. Long after w h a t you 've said a b o u t a partic­
u lar su b je c t has b e e n forgotten, y o u r c a r to o n will b e rem em b ered and
34 T h e N e w H andbook on Co g nitive T h erapy T ech n iq u es

will help clients c o p e with tro u b le so m e situations. O u r clients have

reported that the follow ing c a rto o n s (Figure 1.4) h av e b e e n th e m ost
useful to them.
Computers. Therapists can also illustrate their c o n ce p ts th ro u g h th e
use o f com pu ters. C om p uters n ow a c c o m p a n y m ost o f o u r individual
and all o f o u r grou p sessions. C o m p u ters h a v e th e a d v a n ta g e o f b e in g
m ore flexible th an o th e r teaching m etho d s; for individu al th erap y ses­
sions, th e therapist can h a v e a secon d m o n ito r for clients to view the
therapist's co n ce p ts and their ow n resp onses im m ediately. For grou p
therapy w e gen erally run the w h o le session from a lap top c o m p u te r
c o n n e c te d eith er to an LCD p ro je c to r or to a la rg e -sc re e n T V th ro u g h
a TV' scan converter. T h e therapist can use an electro n ic m a rk e r to
illustrate th e m a in points sh o w n o n th e screen.
C o m p u ter software, su ch as "Ideas th at M a k e You Feel," b y M artin
Sandry (1992), is available to help clients learn concep ts. Therapists can
also create their ow n program s b y u sing a s c a n n e r and digital cam era.
S c a n n in g se lf-h e lp m anuals, cartoo n s, h o m e w o r k assignm ents, o r key
principles o f their therapy for clients to review' o n th eir ow n c o m p u t­
ers can also b e helpful.
O ne o f th e m a jo r benefits o f using com p u ters in therapy is that it
saves the therapist's tim e and th e client's m oney. If a c o m p u te r w ith an
interactive program is placed in the therapist's w aiting ro o m , clients
can learn certain key principles b efo re or after a co u n selin g session.
Teaching clients as m uch as possible with co m p u ters reserves th e m ore
expensive th erap y sessions for individualized instruction. For exam ple,
the principles discussed in the present ch ap ter (basic formulas, A -B -C
analysis, etc.) can b e m ore readily taught to clients w ith a co m p u te r
program th a n b y th e therapist, but the in fo rm a tio n in th e chapters that
follow (finding a client's specific Bs o r selecting individual cognitive
change techniques) is b etter covered in fa c e -to -fa c e sessions.
Clients ca n also use c o m p u ters to practice s o m e o f th e cogn itiv e
c h a n g e techniqu es. Clients can carry p alm top c o m p u ters to m o n ito r
th eir thoughts, to practice their co u n te rs (see ch ap ters 6 an d 7), o r to
prom p t the use o f certain cogn itiv e restru ctu rin g te c h n iq u e s (see New­
man, Kenardy, H erm an, & Taylor, 1997).

C om m en t
T h e learning m e th o d s presen ted are a d ju n cts to therapy; th ey do
not replace th e n ecessa ry e n c o u n te r b e tw e e n th e therapist a n d the
client. *
Teaching the ABCs 35

FaiRY Taie O V tR PRO O F O P n n iS M f

IT’S T h e C o n R a m b o Lizard

SUPCRPflREftT!

F lG U R F. 1 . 4 . T h e r a p e u t ic c a r t o o n s (1. M e M u llin & C a sey , 1 9 7 5 ; 2. M e M u llin &

G e h lh a a r , 1 9 9 0 a ; 3. M e M u llin , A ss a fi, & C hapm an, 1 9 7 8 ; 4 . M e M u llin ,
G e h lh a a r , & Ja m e s , 1 9 9 0 )
 T h e N e w H andbook of Co g nitive T herapy T ech n iq u es

F u rth er in fo r m a t io n
N eim eyer and Feixas (1990) fo u n d th a t clients w h o were req u ired to
d o h o m e w o rk with their cogn itiv e therapy did b e tte r th a n clients w'ho
had the sa m e th erapy w ithou t hom ew ork .
N ew m an and colleag u es (1997) effectively used p alm top co m p u ters
w ith p a n ic-d iso rd e r clients an d fo u n d th e results c o m p a ra b le to reg­
u lar cogn itive b eh av io ral therapy. C om p uters h a v e b e e n sh o w n to aid
in th e im p lem en ta tio n o f a n u m b e r o f cogn itiv e restru ctu rin g tech ­
niques (Buglione, DeVito, & Mulloy, 1990; Chandler, Burck, Sam p son ,
& Wray, 1988; Selmi, Klein, Greist, Sorrell, & Erd m an, 1990).
Extensive research has b e e n d o n e o n the effectiveness o f m an u als
and self-h elp b o o k s (know n as b iblio th erap y) as a n a d ju n ct to the
client's regular th era p e u tic sessions (see G ould, Clum, & Shapiro, 1993;
Ja m iso n & Scogin, 1995; Scogin, Jam ison, & Davis, 1990; Sm ith, Floyd,
Scogin, & Jam ison , 1997; Wehrly, 1998).
Possibly th e b est gu ide to g o o d self-h elp b o o k s is The Authoritative
Guide to Self-Help Books (Santrock, M in nett, & C am pbell, 1994). It n ot
o n ly lists th e b o o k s b u t also rates their usefulness. For so m e o f the
best b o o k s out now', see Ellis (1995), Ellis and Lange (1995), Ellis and
Tafrate (1997), Freem an and D ew olf (1995), and Freem an, Dewolf, and
Beck (1992).
M ichael Free (1999) has 12-session m u ltim ed ia p sy ch o ed u catio n
program . His b o o k co n ta in s all th e m aterials need ed to c o n d u ct the
grou p : overheads, hom ew ork , fully scripted m in i-lectu res, exercises,
guidelines for checking h o m e w o rk , handouts, a n d m asters for visual
resources that can b e directly p h otocopied.
 TW O

Finding the Beliefs

T h e b a s ic A -B -C f o r m u l a is simple. W hat is not sim ple is having

clients apply it to th eir lives. Clients e x p e rie n ce the greatest difficulty
w ith find ing th e correct B. M a n y clients pick th e first cogn ition that
co u ld b e even vag u ely co n n ec ted to their em otions, and they then
sp e n d th eir tim e and e n e rg y try in g to ch a n g e it. Later they m a y dis­
co v e r that th e y h av e wasted their efforts b ec a u se they picked the
w ro n g thought.
To find th e correct cognitions, clients first need to learn that B
stan d s for m a n y types o f internal processes. Bs are n ot ju st a su b v o ­
cal la n g u a g e or im ages that clients generate. These are Bs, but Bs are
also m u c h m ore. To give clients ev en a rou gh idea o f th e diverse types
o f co g n itio n s Bs en com p ass, w e h and o u t th e follow ing list.

• S e lf-talk • M en tal associations

• Self-efficacy • C ognitive con d itionin g
• Perception • S elf-co n cep t
• Selective atten tion • Images
• Selective in atten tion • Selective m em ory
• A ttributions • G estalt patterns
• Labels (words and phrases) • T h em es and stories
• Explanations • Superstitions, im aginations,
• Exp lanatory style ju d gm en ts
• Categories • C onclusions
• C ognitive m aps • Self-in stru ctio n
• S e lf-d em a n d s • A ssum ptions
• Life th em es • Reifications
 T h e N e w H andbook oi- Cognitive T h erapy T echniq ues
38

• In tern al scripts Linguistical p rototypes

• Prototypes Pattern c o n n e c tio n s
• IC M s (idealized cogn itive m od Brain organ ization
els) C ognitive sch em as
• Personalized m yths G estaltens
• In fo rm atio n al processing Primal m o d es
• Neural netw orks

Therapists can help clients m a k e se n se o f this lon g list o f lab els b y

exp lain in g that th ese Bs all o c cu r at different times. Like d o m in o e s
falling, each o n e o f th ese m en tal p rocesses triggers th e next o n e until
th ey g a th e r e n o u g h force to cau se clients to feel a certain e m o tio n or
act in a particular way.

A_____________Q Cb >
B B B B B B B B B

A = activating ev en ts o r stim uli

Bs = different kinds o f beliefs and cogn ition s
Ce = em o tio n a l reaction— w hat w e feel
Cb = b eh a v io ra l reaction — w h a t w e do

E x p e c t a t io n s

Principles

S o m e Bs o c c u r b e fo re the ev en t (A) appears. T hey are o ften b ro a d

p hilosoph ies o r ways o f lo o k in g at th e world th at feed in to h o w clients
regard th e event.

----------- 1------------------------ A ----------------------------- Ce ----------- Cb ------------- ►

B
E x p e c ta tio n s

Expectations are w hat clients require o f themselves, others, and the

world itself. They are the slide rules that clients use to decide w h ether
they succeed or fail, the dem ands they place o n them selves ab o u t how
well they should perforin. Clients may have too high or to o low expec­
tations about themselves, about others, o r ab o u t the world. W h e n clients
require that they reach w hat they expect, expectations b e c o m e dem ands.
Finding the Beliefs 39
/

O ften, u n realistic e x p e cta tio n s are the so le cau se o f clients' e m o ­

tional problem s. Perfectionist clients m a k e im p o ssib le d e m a n d s and
set th eir ex p e cta tio n s so h ig h that they can never m e a su re up. These
clients m ay alw ays feel like failures. They m ay b e c o m e suicidally
depressed b e c a u s e they receive a grad e low er than th ey w ere ex p ect­
ing in a class, o r th ey m ay b e c o m e terrified if they can't control cer­
tain in tern al processes. For exam ple, the key ex pectation for m an y
a g o ra p h o b ics is: "I m u st keep from getting anxiou s, or if 1 get anxiou s
I m u st red uce it right away." O th er clients en d u re co n stan t anger
b e c a u s e they ex p ect e v e ry o n e to act in a ju st and rational way and
t h e n get a n g ry w h en p e o p le d o n ’t. S o m e depressed clients' ex p ecta­
tions are so low th at th ey give up a n y en d ea v o r w ith ou t trying.
Before an A even takes place, clients enter the ev en t carrying a
h e a v y load o f e x p e cta tio n s and d em an d s that will d eterm ine w h ether
th ey view th e A as g o o d or bad, a success o r failure, positive o r neg­
ative. T h e in trinsic w o rth o f the A is u n im p o rtan t; it is assessed only
th ro u g h th e colored glasses o f clients' expectations.

M eth o d
1. Have clients focu s on a p rob lem situation and im ag in e it until it is
sensed clearly.
2. Have th em d ecid e w h a t the b est o u tc o m e could b e for the situation,
a n d ask th em to record their an sw er o n a te n -p o in t scale. T he scale
is a n c h o re d b y w h at clients im ag in e the b est a n d the worst things
are that could h a p p en in their life. For exam ple, w in n in g a Nobel
prize (10) could b e c o m p a red to b ein g diagnosed with term inal c a n ­
c e r (0).
(0) |______________________________ |_____________________________ |(10)
w orst life ev en t (5) best life event
(Draw this for the client.)

3. Have clients im agine th e best and worst possible ou tco m es in the

p ro b lem situation an d m ark their scores on the scale.
|____________ X_________________ |_______________ X _______________|
worst o u tc o m e best o u tco m e

4. Have y o u r clients decide w h ere th e ju st-re a so n a b ly -a c c e p ta b le

(JRA) p o in t is. Explain JRA as, "W hat o u tco m e would you consider
just reaso n ab ly accep table— th e m in im u m necessary for you to
co n sid er the event barely positive."
 T h e N e w H andbook qe Co g nitive T herapy T echniq ues

i x _____________ ___x ____ ;_____ x _______________ i

w orst o u tc o m e JR A b est o u tc o m e

5. Finally, h av e y o u r clien t fill out a variety o f scales for different p ro b ­

lem situations u sin g th e sa m e proced ure. You will th e n b e a b le to
establish w h at exp ectations, self-d em an d s, o r e n title m e n ts th ey are
using to ju d ge them selves and others.

These scales will establish the variou s p oin ts o n th e client's slide

rule o f expectations. O b serv e how the client's m e a su rin g scale differs
from m ost p eople w h o h a v e faced sim ilar situations. For exam p le, the
follow ing scales sh ow various distortions.

A l l - o r - n o t h i n g T h in king
I X ________ I___________________________ _ x _ l
worst b est

The e n d points on the scale are to o far apart, to o extrem e. T h ere is

a large difference b etw e en th e b est and w orst p ossib le o u tcom e.
Clients w h o sco re in this w ay often catastrop h ize a n d dram atize. T hey
b eliev e that eith er s o m e th in g w onderful o r s o m e th in g terrib le will
happ en , even in m u n d a n e situations. For exam p le, a p r e -m e d stu den t
faced with getting a B m in u s in a ch em istry co u rse im ag in es n o t get­
tin g into m edical sch o o l and sp en d in g th e rest o f his life w a n d erin g in
city alleys eating out o f g a rb ag e cans.

D e p re ss ed T h inking
I X X _____________ I_______________________________ I
worst best
This scale is to o narrow — b o t h scores are in th e negative zone.
S o m e depressed clients see little difference b e tw e e n th e w orst an d b est
o u tcom e. For these clients even th e b e st o u tc o m e s are n egative; there
is little to m otivate th em to strive to ach iev e th eir goals.

Perfectionist T h inkin g
I X __________________________________________________I_) R A __X ____ I
The JRA is lo o far to th e right, a n d a lm o st e q u iv a le n t to th e b est
ou tcom e. This scale is sy m p to m a tic o f p erfectionist clients, w h o allow
n o ro o m for error. If they don 't get th e best, th e y feel like failures.
Also co n sid er w h eth er y o u r clients w ould draw th e scales differ­
ently for others th an for them selves. For exam p le, an g ry clients often
Finding the Beliefs
/

req u ire o th ers to ach iev e a m u c h h ig h er JR A (toward the b est o u t­

com e). T h ey d e m an d b etter b e h a v io r from others in variou s situations
t h a n th ey ex p ect o f them selves.

E x a m p le
Having expectations that are too high can create lifelong problems.
Years ago, m y colleagues and 1 w orked with a typ e o f client w hose prob­
lem turned out to b e quite baffling. These clients had strong feelings o f
inadequ acy and very' low self-esteem, a n d would attack themselves
unmercifully. They believed themselves totally worthless and suffered
from depression so strong that they often contemplated suicide.
W e had d iag n osed th ese clients as h av in g in a d e q u ate personalities,
b u t in fo rm ally a m o n g ourselves w e often called these people "INPS"
C lients ("I'm n o th in g b u t a piece o f shit" clients). We w ere b e in g nei­
th er cru el n o r cavalier; w e sim p ly believed th e INPS label described
th e clients' p ro b le m m o re accurately. It w asn't that th ese clients were
really in a d e q u a te p eople; it w'as that they th ou g h t th ey were.
O th e r therapists h a d tried to help th em b y attem pting to b o o s t their
d ism ally low self-esteem , persu ad in g th em to like th em selves and
e n c o u ra g in g th em to stop their self-attacks. Little worked.
A client n a m e d Al w as a typical exam ple. He th o u g h t h e was totally
rotten inside and cou ld n 't find o n e positive thing a b o u t him self that
h e liked. He believed h im s e lf ugly despite th e fact that w o m e n kept
ch attin g with h im and m a k in g passes. He th o u g h t he was uncaring,
b u t o n the w e ek en d s h e to o k out fatherless boys for the Big Brothers
organization.
His n egative attitude caused him a great deal o f pain a n d produced
in so m n ia and h y p erso m n ia. He b e c a m e an tih ed on ic, had recurring
crying spells, an d fre q u e n tly th o u g h t a b o u t suicide, w h ich h e had
a ttem p ted twice.
Al's self-p e rce p tio n s were totally irrational, b u t even m ore con fu s­
ing was the way that h e resp on d ed to a n y attem pt to c h a n g e his atti­
tude. He gen erally acted w e a k a n d passive, but w h en therapists tried
to reform his b e lie f h e w ould fight th em as h ard as h e could, relin­
q u ish in g his wimpy, passive d e m e a n e r a n d fighting any suggestion
th at h e w asn't a totally w orthless individual. Al times h e b e c a m e hos­
tile and aggressive toward the idea that h e m ight b e adequate, insist­
ing and ev en d e m a n d in g that h e was worthless. He sim ply wouldn't
tolerate a n y su gg estion that h e w asn't o n e o f the m ost despicable
h u m a n b e in g s o n th e planet.
 T h e N ew H andbo o k of Cognitive T herapy T echniq ues

This client's b e lie f was a puzzle. He w as in a great deal o f pain and

k n e w that it was his attitude th a t was ca u sin g it, yet h e did ev ery th in g
h e could to hold o n to his self-d ep recia tin g belief.
T h e p rob lem was finally resolved b y identifying Al's e x p e cta tio n o f
himself. His core p h ilo so p h y was that h e was an Einstein. This was not
ju st a wish b u t a firm ly felt attitude. He b e c a m e upset w h en o th e r
p e o p le treated h im as an ord in ary m ortal; it b o th e r e d h im w h en h e
h a d to d o su c h m u n d a n e things as b a la n cin g his c h e c k b o o k o r taking
out th e garbage.
W h at b o th e re d A1 m o re th a n a n y th in g was his o w n d iscou rage­
m e n t a b o u t himself. Every tim e h e m a d e a m istak e h e w ould attack
h im self u n m ercifu lly for m a k in g stupid errors, until after a w h ile he
w as co n su m e d by depression and tu rn e d into an INPS.
"It's b ad en o u g h for a n y o n e to m a k e mistakes," h e w o u ld say, "but
it's intolerable for m e (an Einstein) to keep m ak in g them."
W h a t's m o re despairing th a n a person w ith the cap acity o f an Ein­
stein living th e life o f an ord in ary m ortal and h av in g no o n e in the
world recognize his ex cep tio n a l w orth?
Friends u nw ittingly fed Al's attitude b y trying to b o o s t his ego; this
sim p ly raised his ex p e cta tio n ev en further, m a k in g th e contrast
b etw e en his real and ideal self even larger. T h e result was th a t A1 felt
m o re depressed.
A1 believed h e was inferior b e c a u s e o f his se lf-d e m a n d an d self­
ex p ecta tio n ; h e knew that his real ach iev e m en ts in life didn't m e a su re
up o n his perfectionist exp ectations. Each tim e h e attacked h im s e lf he
reinforced his b e lie f that h e really was an Einstein, albeit an Einstein
w h o kept m e ssin g up. From his perspective, if h e stop p ed th e self-
attack h e w ould b e adm itting that h e w asn't special.
T he ap p roach w e to o k in co u n selin g was n o t to p rop up his flag­
ging ego, b u t rather to focus o n his b e lie f th a t h e was an Einstein.

C om m en t
C o g n itiv e r e s tru c tu rin g th e r a p y differs fro m oth er c o g n itiv e
ap p roach es in that it is crucial to g a th e r th e list o f client beliefs, atti­
tudes, and p h ilosophies first. O n ly after the list is c o m p le te sh o u ld the
b e lie f system s b e ch allen g ed ; a n y earlier ch a llen g e will p rom p t the
client to defend them , argu e against the therapist, an d b e far m o r e ret­
icent a b o u t telling th e th erap ist a n y m o re o f his or her private e x p e c ­
tations. This results in an in a ccu ra te o r in c o m p le te list o f the client's
self-d em and s.
Finding the Beliefs
43
/

The therapist sh ou ld r e m e m b e r that th e p lacem en ts o f Bs o n the

tim e lin e are m o re descriptive th a n theoretically precise. S e lf dem ands
a n d m a n y o th e r Bs can b e placed at o th e r locations; so m e Bs, such as
se lf-co n cep t, m ay exist all alon g th e tim eline.

Further In fo r m a tio n
Safren, Juster, & H eim b e rg (1997) discovered that ex p ectation s are
crucial to various form s o f cognitive psychotherapy. W hittal &
G o etsc h (1997) fou nd that the ex p ecta tion o f suffering a panic attack
w as significantly related to agorap hobia.
S o m e early studies su p p ort the im p o rta n ce o f ex p ecta tion s on the
effectiveness o f rein fo rce m en t (Farber, 1963; G holson, 1980; Spielberger
& DeNike, 1966; VVeimer & Palermo, 1974). In th ese studies, reinforce­
m e n t didn't c h a n g e b e h a v io r u nless th e su bjects' ex pectation s were
taken into accou nt. If su b jects exp ected a greater rein forcem en t than
they received, th ey in turn treated the actual reward as a punishm ent.

S e l f -E ffic a c y

— I------------ A --------------------------------- Ce ^ C ,

self-efficacy

P rinciples
Alfred Bandura (1995) and his colleagues have noticed that clients'
beliefs a b o u t su cceeding are crucially im portant in determ ining
w h eth er clients reach their goals. W hat they accom plish is based on
w hat th ey th in k they can accomplish. Efficacy is inversely related to
expectations; expectations that are to o high often lead to a reduced
sen se o f b ein g ab le to accom plish goals— low self-efficacy. Clients judge
that they d o n ot have the pow er to reach their own high demands.
M o st o f the literatu re o n self-efficacy em phasizes th e d a m a g e o f
low self-efficacy, b u t in recent years self-efficacy th a t is to o high has
b e e n targeted as eq u a lly dam aging. Exam ples o f this variety are alco­
h o l- an d d r u g -d e p e n d e n t clients w h o m istakenly believe that they
h av e the ab ility to control th e use o f drugs ("I c a n stop after a coup le
o f drinks") a n d psychotic patients w h o b eliev e them selves ab le to c o n ­
trol their h allu cin ation s throu g h w illpow er alone.
44 ___________ Thf Mfw Hanhrook OF COGN H Kf THFRAPY TF.CHNtQ.llES.
. X ... ""

M eth o d
1. H ave th e clien t relax a n d focu s o n a particu lar A -C p ro b lem situ a -
tion. ,
2 Ask th e client to predict his o r h e r ability to successfully so lv e th e
situation. H ave h im o r h e r place the prediction o n a c o n tin u u m .
(You m ay use the sa m e c o n tin u u m s draw n for expectations.)

1 _I________________________ X-------1
low c h a n ce o f success hig h c h a n c e o f success
"I am 90% certain I can control m y anger even when m y wife yells at
me."

5. Tell th e client to sw itch th e prediction and n o tice how' it ch an g es the

feeling. For exam p le, "Im agin e th a t you w ere o n ly 10% su re that
y ou w o u ld n 't hit y o u r wife w h e n you got angry. How w o u ld you
feel th e n ab o u t co n tin u in g y o u r a rg u m e n ts w ith her, and w h a t
w o u ld you feel a b o u t y o u r past assaults?"
4. G o th ro u g h a variety o f situ atio n s to establish th e client's m e a n self-
efficacy. Is it to o low or to o high?

E x a m p le: T he Story o f M ike

This case is a g o o d ex a m p le of self-efficacy that is t o o high.
A client, Mike, c o u ld n ot m a in ta in g o o d relation sh ip s w ith w o m e n
a n d h ad a history o f failed love en co u n ters. Despite p ossessin g so m e
skills and m u ch creativity, h e w asn't successful at w o rk b e c a u s e he
refused to do the m e n ia l tasks c o n co m ita n t in a n y p osition ; h e w ould
usually b e fired. He had em o tio n a l p rob lem s th a t w e re in itially m in o r
but built into pow erful u pheav als b e c a u s e h e w as in c a p a b le o f toler­
ating even th e sm allest frustration. M ik e felt like a n e m o tio n a l mess.
M ike's p rob lem s had m a n y causes, b u t a m a jo r c o n trib u to r was
inap p ro p riate self-efficacy. He was th e y o u n g est in a large family, and
his m o th e r had suffered tw o m iscarriages p rior to his b irth. T h e d o c ­
to r had w arn ed h e r th at b e a r in g a n o th e r child m ight kill her, b u t she
liked m o th e rh o o d and d esp erately w an te d o n e m o re child. To th e
surprise o f his father, mother, an d the m ed ical profession, M ik e was
born. His m o th e r th e n had a h y ste rec to m y assu rin g th a t h e w as h er
last.
M ike was an attractive b a b y an d was treated like a prince b y e v ery ­
 Finding the Beliefs
/

o n e in th e family— particularly his m other. W h e n M ike started to form

his self-efficacy, h e lo o k ed in the m irror his fam ily was hold ing and
saw th e reflection o f a special child, adored b y his fam ily and treated
as royalty. He kn ew n o th in g a b o u t his m other's miscarriages, h er hys­
terectom y, o r th at h e was th e last child possible. All h e knew was that
h e was not like o th e r b o y s; h e saw h im s e lf as a u n iq u e gift from God.
Life w as pleasing for M ike until h e w ent to school, w h ere the o th er
child ren treated h im like a n o r m a l h u m a n b ein g rather th a n a prince.
His sc h o o lm a te s didn't n eed h im as his fam ily did, b u t he didn't
u n d erstan d this. All h e knew was that he w asn't receiving special
treatm ent. He g o t angry w ith his peers and d em an d ed that th ey serve
h im properly, b u t this further en ra g ed them , so they teased and
ridiculed him . He b e c a m e th e b ru n t o f th eir practical jokes. This just
m a d e M ike feel w orse; h e b e c a m e angrier and m a d e m ore dem ands.
S o o n a v iciou s cycle had developed until M ike had no friends at all.
He b e c a m e a social isolate.
The treatm en t M ik e received from his classm ates m ight h av e m ade
h im w o n d e r w h e th e r th ere was so m eth in g w ron g at hom e, b u t it did­
n't. Instead M ik e c o n clu d ed that s o m e th in g w as w rong at school. He
decided th at his sc h o o lm a te s w ere je a lo u s o f him b ec a u se th ey recog­
nized h ow special h e was an d h ow inferior they were.
He c o n tin u e d this way th ro u g h o u t his life. W h e n his girlfriends
didn't treat him as his m om had, it was ob v iou s to him w hat was
w ron g— w ro n g girlfriend! He spent m ost o f his adult years searching
for a w o m a n w h o had e n o u g h sen se to treat him properly; h e never
fou n d her. He o n c e told me, "W ith w o m en 's liberation, it's really hard
to find a g o o d w o m a n nowadays."
W h e n M ike ex p e rie n ced n o rm a l fears, frustrations, and petty
a n n o y an ce s, his reaction w as o n e o f rage. "It's u nfair that life is so hard
on m e; so m e th in g is w rong; it sh ou ld n 't b e this way. I h av e th e right
to get ev ery th in g I want!" W h e n a sales clerk did not wail o n him
im m ed ia tely h e w o u ld throw a te m p e r tantru m and walk out o f the
store.
M ike's p rob lem was fairly clear. He had w h at I call th e "Prince in
Disguise Sy n d rom e"— h e believed that h e had special pow er and was
entitled to ex tra o rd in a ry treatm en t from the world. His self-efficacy
was so high, distorted, and unrealistic that it kept him from accepting
th e n orm al frustrations th a t w e all have to deal with. Instead o f c o p ­
ing, h e ju st sat there feeling cheated. His attitude was created by the
w arp ed se n se o f self-efficacy h e had learn ed from his family.
 T h e T J e w . H andbo o k ..q l Cq g n i t m T h erapy T echniq ues

V V

C om m en t
B ecause th e y are closely co n n ec ted , self-efficacy is u su ally discussed
with self-e x p e cta tio n ; th ey are sy n ergetically related. For exam ple,
high e x p e cta tio n low self-efficacy is o n e o f th e m ost d a m a g in g c o m ­
binations. Depressed clients o ften h av e very h ig h se lf-d em a n d s
a cco m p a n ied b y little h o p e that th ey can ach ieve them .
In practice, w e often h a v e patients rate b o th variab les o n the sa m e
c o n tin u u m as sh o w n below.
|_________ E___________ |____ JR A _____________ ___________ -I
low m ed iu m
"Sh ow m e o n th e scale w h at you w ould co n sid er a ju s t - r e a s o n a b l y -
accep table result (JRA). Now m a rk dow n w h a t result you th in k y ou
can ach ieve (efficacy)." Clients w h o view ed th eir p ro b lem s in this way
w ould feel desp on d en t. They w o u ld see little rea so n to try sin ce their
ex p ecta tion o f success was so far from an o u tc o m e th at w o u ld b e even
m in im ally acceptable.

Further In fo r m a tio n
A lbert B an d u ra researched th e co n ce p t o f self-efficacy an d is th e
m a jo r theorist and w riter in th e area. S ee Band u ra (1977a, 1977b, 1978,
1982, 1984, 1995, 1997; Bandura, Adams, Hardy, & Howells, 1980; B a n ­
dura, Reese, & Adams, 1982; B a n d u ra & Sch u n k, 1981; Schwarzer,
1992). S o m e b ehavio rists have argued th at self-efficacy is c o n c o m ita n t
with goal-d irected behavior, b u t n ot a ca u se (Hawkins, 1992, Hayes
1995). Bandura c o u n te r-a rg u es that self-efficacy is a cen tral and
im p o rtan t d e term in a n t o f h u m a n b e h a v io r (Bandura, 1996).

S e l f -C o n cept

------------ 1------------- A -------------------------------Ce ----------- Cb --------------- ►

B
se lf-co n cep t

P rinciples
Self-efficacy an d e x p e ctatio n s can b e g ro u p e d into w h a t has tradi­
tionally b e e n called self-concept. T h ere is p ro b a b ly n o n ee d to in clud e
se lf-c o n c ep t as a separate ca te g o ry sin ce its c o m p o n e n ts c o m b in e the
tw o Bs o f self-efficacy and exp ectations, b u t th e literatu re a n d history
 Finding the Beliefs
/

of this v a riab le are so m assive th a t it does deserve a separate listing.

A person 's se lf-c o n c ep t precedes en v iro n m en ta l stimuli. It is o n e o f
the m ost pow erful Bs th at d eterm in es h ow p eople act, and a key deter­
m in a n t o f w h e th e r they feel that their lives are happy o r miserable.

E m e r g e n c e o f Self-Concept
D e v elo p m en ta l psychology' suggests th a t th e self-co n cep t em erges
grad u ally du ring infancy. Infants' w orlds b e g in as a bizarre, buzzing
con fu sion . T hey h av e instincts that cau se them to grab, suck, cry, or
wet, b u t n o t m u c h else, an d th eir self-id ea and perception o f th e en v i­
ro n m e n t are m erged into o n e aggregate; M o m m y and b a b y are one,
th e b o ttle and h a n d are one. There are few separations.
As b a b ies b eg in to differentiate th e outside world, they b r e a k things
dow n in to M o m m y a n d n o t -M o m m y — th en Daddy, n asty older
brother, an d Pat th e cat c o m e along. T h e rest o f h u m a n ity em erges as
" n o n e o f th e above."
Carried a lo n g with this o th e r aw-areness, a different typ e o f cog­
n iza n ce em erg es— th e self. Initially th e se lf is ju st a n o th e r o b je ct that
infants b e g in to notice— an a m o rp h o u s m ass o f hunger, sounds,
stra n g e smells, a n d m o v em e n ts w h o se im pressions seem closer to
th em th a n o th e r th in gs in their en v iro n m en t. Infants don 't have the
c o n ce p t that th ese things b e lo n g to them. Eventually, these closer
things start g a th e rin g a ro u n d a co n ce p t w e later call "self." O th er sen ­
sa tio n s are separated into not-self.
As th e se lf-c o n c ep t em erges, o th er aspects are gathered, including
em otio n s. "This thing called s e lf is fearful, h a p p y hungry, o r angry'." O f
c o u rse infants d o n 't h av e th ese words, b u t th e feelings are present and
are identified as b e lo n g in g to th e m rath er than to so m e o n e else.
W h ile the child is still at a y o u n g age, a very im p o rta n t th in g takes
place: th e s e lf starts g a th e rin g an overall value. Children start placing
a positive o r negative w orth o n this self: "This is a g o o d self. This is a
bad self. This is a flawed self. O thers have b etter selves. This is an evil
self. This s e lf has merit. This s e lf is worthless. This se lf is sick."
This v alu in g process is crucial, b ecau se children start acting accord­
ing to the value they h av e assigned them selves. If they' ju d g e the self
as bad, t h e y start actin g badly'. If th ey think they' are incom petent, they'
act incom petently. Instead o f passively responding to the env iron m en t,
this valued s e lf starts ch an gin g th e en v iro n m en t and reaffirming itself.
For exam ple, th e in co m p eten t self w ithholds effective action, fails on
m o re tasks, and views th ese failures as fu rther ev id en ce o f in com p e­
tence. O ver tim e these ratings b e c o m e self-fulfilling prophecies.
 ...Th e N l w .Ha n b b o o o i Co g nitive T herapy T echniq ues

T he v alu e clients h av e assign ed to th em selv e s can h av e h u g e stay

ing power, and can last th ro u g h o u t their life u n less th ey activ ely do
s o m e th in g to c h a n g e it. T h eir v a lu e b e c o m e s the cen tra l stru ctu re
th ro u g h w hich th ey filter all th ey feel, think, do.
W h e re does this ratin g c o m e from ? How do th ey form th e ir self
w o rth ? T h ere is o n e p ro b ab le answer. People learn th eir v a lu e by
a b so rb in g th e rating o f others. W h e n th ey are ch ild ren th ey c a n n o t
accu rately appraise th e ir ow n m erit; at 7 or 8, ch ild ren are n o t capa
b le o f m ak in g an o b je ctiv e ju d g m en t. So those a ro u n d th e m are the
m irrors throu g h w h ich they ju d g e w h o they are. O th ers sh ow th em
w hat th ey are w orth o r not worth. If their im p o rta n t o th e rs accept
th em , th ey ju d ge them selv es as w o rth w h ile and th e self b e c o m e s
acceptable. But if th ese o th ers treat th e m as if th ey are evil or bad, th ey
interpret them selves as evil an d th at th e evilness lives inside them .
It is at this p oint that th e p ro b lem occurs. If o th ers d o n 't ju d g e
accurately, children's percep tions o f th eir s e lf-w o rth are distorted. Par­
ents' insecurities and p rob lem s m a y ca u se a perverted o r w arp ed
reflection. T h e ch ild is too y o u n g a n d in ex p e rien ced to kn ow th at their
im p o rtan t other's m irror isn't accurate. A child d o e s n o t dedu ce, I am
not a b ad child. My m o th e r spanked m e b e c a u s e s h e is a histrionic
p erson ality w h o is upset b e c a u s e sh e is n o lon g er th e c e n te r o f a tte n ­
tion." T h e sp an ked child will n atu rally co n clu d e th a t s o m e th in g is
w ro n g with him, not w ith his m other. In th e end, th e child accepts
w h a t is reflected b a c k as true, and adopts this distorted view o f self.

M eth od
A lth ou gh th ere are m a n y m easu res o f s e lf-c o n c e p t th a t m a y b e o f
so m e use, p ro b a b ly the m ore v a lu a b le m e th o d for th e cogn itiv e th e r­
apist is to abstract the se lf-c o n c ep t from th e list o f Bs g a th e re d from
th e client.

1. C om p lete th e client's m a ste r list o f beliefs (discussed in c h a p te r 3).

2. Select th e Bs th a t directly refer to self.
3. Find th e positive o r n e g a tiv e 'v a le n ce th e clien t reveals w ith e a c h o f
these beliefs. For exam ple, the B, "The w orld is a b ig an d d an g ero u s
place," d em o n stra tes a s e lf-c o n c e p t of, "I a m w e a k a n d helpless." This
attitude w ould b e n eg ativ e self-valence.

E x a m p le: T he Story o f Cynthia

C ynth ia was b o r n into a d y sfu n ction al family, and w h e n s h e started
to form h er se lf-c o n c ep t at a ro u n d age 7, th e fam ily was in a co n sta n t
Finding the Beliefs 49

state o f uproar. Her fa th er w as an alco h o lic a n d sexu ally abused her

w h en h e was o n o n e o f his binges. Her b ro th e r was a c o c a in e addict
an d b e a t h e r w h en h e was g o in g th ro u g h his w ithdraw al rages. Her
m o th e r w as an e n a b le r w h o kept the family to g eth er b y m in im izin g
all o f th e p ro b lem s a n d preten d in g not to n o tice that the family was
b lo w in g up a ro u n d her. T h e m o th e r felt totally w orthless as a h u m an
b e in g an d c lu n g to o n ly o n e principle— keep the family together, no
m a tter what.
C ynthia's s e lf-c o n c e p t form ed in this terrible env iron m en t. She
con clu d ed , as m ost child ren w ould, that th ere w as som eth in g horribly
w ro n g with her. "I m u st b e o n e o f th e w orst p eople on the planet to
b e treated so badly," sh e thought.
As ou tsid e observers, w e can see th at Cynthia was wrong. We know
it w asn't h e r fault that sh e was b eaten , abused, and ignored. We know
that h e r fam ily was pathological. But C ynthia didn't see it this way.
Her o n ly m irror was the reflection h e r fam ily gav e her. Therefore, her
s e lf-c o n c e p t w as distorted.
W h e n h e r fa th er sexu ally a b u sed her, sh e assu m ed that sh e was to
b lam e. W h e n s h e later learned a b o u t sex, sh e decided th at sh e must
h av e b e e n a bad, evil girl— a slut, ch ea p and dirty. T he o n e tim e she
talked to h e r m o th e r a b o u t h e r dad's abuse, her m o th e r told her that
s h e was lying, th at sh e w as n o t to m a k e a big thing o f it, and to shut
up. C ynthia cou ld n 't h a v e u n d ersto o d that h er m o th e r was in th e ter­
m in al stages o f denial, th at sh e could o n ly survive b y pretending
e v ery th in g was fine.
C ynth ia didn't kn ow th a t her family's sickness had twisted h e r view
o f herself; s h e didn't kn ow th at h e r family was dysfunctional. Seven
years old a n d o n th e receiving en d o f m o u n ta in s o f hate, disgust, and
ab u se, s h e c o n clu d ed th a t sh e was th e cause o f it all.
This m istaken se lf-p e rce p tio n was built o n and en h a n ce d o v e r th e
years. Sh e had survived b y turning o ff her em o tio n a l switches and
b e c o m in g stoical. T he family, ach iev in g a level o f perversion that only
ch em ically d e p e n d e n t fam ilies can reach, judged her d e m e a n o r as
strength. Not h aving a n y o th e r person with even th e ap p eara n ce o f
strength, the fam ily turn ed to h e r for support. Sh e b e c a m e th e fam ­
ily's h e ro and head n u rse; sh e was su b stitu te wife for th e father, c o n ­
fid ante for th e mother, parent to her b ro th er— all at the age o f 14. She
sacrificed h er a d o lescen ce in a d o o m e d attem p t to keep h e r disinte­
grating fam ily tog eth er; b y th e tim e s h e was 22, sh e had m a d e three
su icide attempts.
Clients' view s o f th em selv e s are at their cognitive centers; they are
w h a t m ak es th em tick. T h ro u g h their se lf-im a g e they see all the world
 T u t N e w H andbook oi Co g nitive T herapy T echniq ues

an d all th e p eople in it, and it is this v iew th at can m a k e life ha p p y or

turn it in to a private co n ce n tra tio n cam p.

C om m en t
In the discu ssion o f exp ectations, self-efficacy, a n d se lf-co n cep t, I h a v e
m e n tio n ed that clients can have to o high as well as to o low self­
esteem. W h ile it is difficult for so m e profession als to accept th a t clients
can h av e erro n e o u sly high self-esteem , M artin E. P. S e lig m a n offers a
m eanin gfu l discussion a b o u t so m e o f its effects:

Feelings o f self-esteem in particular, an d h ap p iness in general,

develop as side effects— o f m asterin g challenges, w o rk in g su c­
cessfully, o v e rco m in g frustration and b o r e d o m , a n d w in ning. I he
feeling o f se lf-e steem is a b y p ro d u ct o f d o in g well. O n c e a child's
self-esteem is in place, it kindles fu rther success. Tasks flow m ore
se a m lessly trou b les b o u n c e off, and o th e r ch ild ren se em m o re
receptive. There is n o q u estio n that feeling high self-e steem is a
delightful state to b e in, b u t try in g to ach iev e th e feeling sid e o f
se lf-e steem directly, b efo re a ch iev in g g o o d c o m m e r c e w ith the
world, con fu ses p rofou n d ly th e m e a n s and th e end.
This is ju st w h at m ak es the California rep ort o n self-e steem so
gaseous. It is true that m a n y sc h o o l d ro p o u ts feel low self­
esteem , m a n y pregnant teenagers feel sad; m a n y y o u n g drug
addicts and crim inals feel self-loath in g , and m a n y p e o p le o n
w elfare feel unworthy. But w h a t is cau se an d w h a t is effect? T he
California report, w ith its "vaccine" rec o m m e n d a tio n s, c la im s that
th e feelings o f low self-w orth ca u se th e sc h o o l failures, th e drug
use, the d e p e n d e n c e o n welfare, and o th e r social ills. B u t the
research literatu re show s ju st th e opposite. Low se lf-e ste e m is a
c o n s e q u e n c e o f failing in sch ool, o f b e in g o n welfare, o f b e in g
arrested— n o t th e cause. (Seligm an, Reivich, Jayucox, & G illham ,
1995, pp. 5 3 -3 4 )

F u rth er In fo r m a tio n
Seligm an has d o n e ex ten siv e w o rk o n th e positive a n d n eg ativ e
effects o f se lf-c o n c ep t to develop his th eo ry o f lea rn e d h elp lessn ess
and learn ed optim ism (Seligm an, 1975, 1994, 1998; Seligm an, Reivich,
Jayucox, & G illham , 1995). Brom ley (1977) ex p lo res th e d e v e lo p m e n t o f
th e self. G u id an o has b e e n oi\e o f the m a jo r co g n itiv e th eorists e x a m ­
FindingJhe_Beliefs__________ 51
/

in in g se lf-c o n c ep t from a d e v elo p m en tal perspective (Guidano, 1987,

1991; G u id an o & Liotti, 1983). In addition, Carl Rogers (1951, 1959) and
G e o rg e Kelly (1955, 1980) m ad e se lf-c o n c ep t the core o f their theories.

A t t en t io n

A ----------------------------- Ce -----------C,
B
attention

P rinciples
S o m e cogn ition s precede e n v iro n m e n ta l triggers w hile others fol­
low them . But atten tion is th e typ e o f cogn ition that occurs at the
sa m e tim e th a t th e A occurs. In fact, this typ e o f m ental process helps
decid e w h a t is and w h a t is not an A.
People's identification o f As is based o n which elem ents they focus
o n and which th ey ignore. The raw inform ation received through their
senses is a myriad o f sights, sounds, smells, tastes, and feelings— viewed
alone, these are ran dom and incom prehensible. Their brains make
sense out o f this kaleidoscope o f data b y form ing raw stimuli into pat­
terns.
People's b rain s tell th em w hat to see and w h a t not to, w hich sou n d
to pick o u t fro m th e m asses o f sounds, w h ich sm ell to identify, which
taste to ignore, a n d w h ich physical sensation will alarm them . If their
b ra in s c h o o s e to disregard so m e in c o m in g in form ation from their
sen ses th e n th e in form ation ceases to exist for them . W h a t affects
th em from th e outside world is b ased on w h a t their brains h a v e told
th e m to pay atten tion to.

M eth od
1. Instru ct y o u r clients to crea te a m en tal picture o f w h at is b o th erin g
th em th e n ex t tim e that th ey feel upset. If th ey can they should
m a k e a sk etch o f th e key co m p o n e n ts.
2. Next, direct th em to create a n o th e r m ental picture with a different
focus. This will b e difficult, b ec a u se th ey will w an t to keep return­
ing to th eir first image. E n cou rage th em to keep practicing, to keep
c h a n g in g their focus. After a w h ile they m ay discover that what
th ey see is fairly arbitrary and based o n w hat they c h o o s e to see.
52 T h e N e w H andbook oi- Co g nitive T h er a py T ech n iq u es

E x a m p le v
I asked an a g o ra p h o b ic w o m a n w h o w as afraid o f leav in g h er
hou se to draw w h at it was like w h en sh e left h e r territory. (Figure 2.1).
Her draw ing illustrates h ow s h e perceived h e rs e lf a n d w h a t sh e
focused on. W h e n sh e tried to leave h e r h ou se, s h e felt trapped, as if
sh e were in a box. T h e b o x would get sm a ller as s h e traveled farther
away from h om e, and th e pressure w o u ld bu ild until s h e feared
exp lod in g o r g o in g insane. S h e focused h e r a tten tio n o n h e r a n x iety
and the feeling o f b e in g trapped. T he m o r e s h e focu sed o n h e r b o d y
sensations, th e m o re scared sh e b eca m e. This clien t was h elp ed w h en
sh e was ab le to shift her a tten tio n to th e outside— th e su rro u n d in g
en v iro n m en t.

C om m en t
W h a t clients attend to is o n e o f the m ost difficult co g n itio n s to dis­
cover. M o st clients are u n aw are th at th ere is a n y th in g else th at th ey
could focus o n in a situation. T h ey b eliev e th a t th e e n v ir o n m e n t
(either internal or external) is cau sin g th e m to focus o n th in gs in the
way th a t th e y do. T h ey d e n y selecting w h a t th ey atten d to, o r w h at
they extract from th e k a leid o sco p e o f stimuli, a n d suggest th at the
stim uli force th em to lo o k a n d focus in th e w ay th at th e y do.
An an x io u s client au to m atically focu ses o n his fears th e m in u te he

F IG U R E 2.1 D r a w in g b y a g o r a p h o b ic c lie n t
Finding the Beliefs 53
/

feels th e least bit o f anxiety. A depressed client believes that o n c e she

e x p e rie n ces sad ness a n d the sense o f hopelessness, s h e can focus on
n o th in g else. An an g ry patient says th a t his an ger overw helm s him,
m a k in g c o n s e q u e n c e s and o b jectiv ity so m eth in g he c a n n o t think
a b o u t. O n e o f th e first lessons to teach clients a b o u t attendin g b e h a v ­
ior is that it is not forced u p o n th em ; they select it.

F u rth er In fo r m a tio n
A tten tion al processes are im p o rta n t in social cognitive th eo ry (Ban­
dura, 1977a, 1996) an d m o d e lin g th e o ry (Bandura & Barab, 1973).
C h em tob , H am ada, Novaco, a n d Gross (1997) found that altering
atten tio n a l focu s was im p o rtan t in red ucing a n g e r in PTSD patients.
A aron Beck and his colleag u es h a v e discovered that attention al focu s­
ing is a m a jo r c o m p o n e n t in in creasing anxiety and depression (Beck
1967, 1975, 1993; Beck, Emery, & G reen berg, 1985; Ju dith Beck, 1995,
1996).

S el ec t iv e M em o r y

--------------------A --------------- 1----------- Ce -----------Cb ---------------►

B
selective m e m o ry

P rin ciples
T h e n ex t cogn ition o n the tim elin e occurs im m ediately after attend­
ing to the A. T he h u m a n b rain searches th ro u g h lo n g - and sh ort-term
m e m o ry to find a n y e x p e rie n ce that m ay m atch w hat it is perceiving.
W h ile trying to interpret stimuli, clients su b vocally ask them selves,
"H ave I seen s o m e th in g like this before? W h at did it turn o u t to b e
th en ? W as it d angerou s, shou ld I b e alarm ed?" This search is crucial. If
clients h a v e n ev er en co u n tered th e stim ulus o r so m eth in g like it
before, th ey don 't k n o w h ow to react to it. They feel con fu sed and
alarm ed until th eir m e m o r y scan finds a match.
T h e difficulty with m e m o ry is th a t it is highly selective and often
grossly inaccurate. M e m o r y is n ot like a storage b o x that hold s sn a p ­
shots o f past ev en ts— recalling so m e th in g is not th e sam e as pulling
o u t an alb u m folder and searching throu g h old photographs. W h e n
clients r e m e m b e r a past ev en t th e y are recreating th e past anew. It is
 T ilt N e w H andbo o k qe Co g nitive T h eea ey T ech n iq u es

their present im pression o f t h e past, not th e actu al past, th a t their

m e m o ry search uncovers.
Clients' m e m o ries consist o f m illions o f events, im pressions, feel­
ings, and thoughts. T heir m e m o ries exist like a gian t ta p estry so large
that th ey can o n ly se e parts o f it. T he part th ey focu s o n is alw ays a
very' small piece o f th e total cloth, and w h a t th e y recall is often biased
d ep en d in g u p o n w h at they desire to r e m e m b e r and w h a t th e y wish
to feel at th e m om en t. Clients often select the m ost reinforcing m e m ­
ory for the situation at hand. If th ey feel angry, th e y c h o o s e to r e m e m ­
b e r previous tim es w h en th ey g o t revenge. If th ey 're lon ely th e y recall
th e closeness and co m fo rt th ey o n c e had. If they feel w e a k th ey re m ­
inisce a b o u t the tim es they felt strong and exercised power, ev en if
such a tim e n ev er actu ally hap p en ed .
T hey call up from their m em ories th e ev en ts th at fit th eir cu rren t
m ood . M a n y clients w h o feel u n h a p p y a b o u t th e p resent c h o o s e to
r e m e m b e r positive things from their past. T h eir c h ild h o o d ap p ears
rosy: T h ey rem em ber the b irth d ay presents, th e rom an ces, the
a ch iev em en ts; they selectively forget th e sicknesses, th e d isap p o in t­
m ents, th e b ro k en hearts, a n d th e pain.
Each lim e that clients rem em ber, th ey c h a n g e th e past; t h e y rep aint
w h at h a p p e n e d a lon g tim e ago w ith present bru sh strokes. T h e n ew
picture is based o n present feelings, th ou ghts, desires, and wishes. T he
actu al past has lo n g sin ce ceased to exist for th em ; it d isap p eared in
the distant past lim e a n d can no lon g er b e accu rately retrieved.
S o m e clients o b je c t to th e idea that their picture o f th e past is based
o n present feelings, thoughts, desires, and wishes. T h ey m a y ask, "Isn't
the past th e past, w hat hap p en ed , h ap p en ed ? How can I c h a n g e s o m e ­
th in g that d o esn 't exist a n y m o re ? Isn't th e past total and c o m p le te ju st
the w ay it is?"
Rationally this is true; the past is unalterable, b u t the client's m e m ­
ory o f the past can b e changed. T h e client's view o f the past is quite
incom plete. N obod y can rem em b er things exactly th e w ay they w ere—
h u m a n m e m o ry is too p o o r for that, and is selective as well. W e re m e m ­
b e r w h at we ch oose to r e m e m b e r and forget w h at w e c h o o se to forget.

M eth o d 1
Explain th e principles o f selective m e m o r y to y o u r clients. You m a y
wish to offer a description sim ilar to th e h a n d o u t o n selective m e m ­
ory th a t w e give to m a n y o f o u r clients.
Finding the Beliefs 55
/

M eth o d 2
1. Vague remembering. Ask y o u r clients to r e m e m b e r a past event, n ot to
recall all o f th e details b u t sim p ly to allow the overall m e m o ry o f
th e ev en t to em erge. H ave th em w rite dow n o r audio record what
th ey recall.
2. Relaxation. Next, h av e th e m relax. Teach th em sy stem atic relaxation,
or h av e th e m listen to a n a tu re tape or relaxing music.
3. M eticulous remembering. Have th e m im ag in e traveling b a ck in time to
th e early scenes. Pick a specific sc e n e to focus on. Tell th em to use
all o f th e ir sen ses to fill in th e scen e : Vision— w h a t colors, lighting,
o b je cts, m o v em e n ts, p ersp ectiv e d o th ey see? S o u n d s— can they
h e a r p e o p le talking? Do th e y h e a r b a ck g ro u n d sounds, music, p e o ­
ple talkin g in th e n ex t room , traffic outside? Sm ells— w hat odors
d o th ey n o tice? K inesthetic— are th ey m o v in g o r stan d in g o r lying
d ow n ? E m o tio n a l— are th e feelings h appy? sad? angry? scared? In
w h at c o m b in a tio n an d stren gth ? G o th ro u g h e a c h step; d o n 't ju m p
a h e a d or generalize. U se as m u c h detail as possible. T h eir m e m o ­
ries m a y b e stim u lated b y u sing aids su ch as photos, diaries, or let­
ters. R em ind th em o f w h at o th e r ev en ts w ere h a p p e n in g at this
time. Use a n y cu es that m a y rem in d th em o f this earlier time.
4. Record. Jot d ow n w hat th ey rem em bered .
5. Com pare th e first re m e m b ra n c e (vague rem em b erin g ) with th e last
(m eticu lou s rem em bering). W h a t did th ey fail to rem em b er? W hat
did th ey forget?

E x a m p le
Clients' m em ories can b e so inaccu rate th a t they m ay recall events
that n ev er h app ened . O n e client spent m a n y h ou rs discussing th e time
her u n cle sexually abused h er w h en sh e was ten. W h e n she did the
m eticu lous rem em b erin g part o f the exercise sh e recalled that her
uncle had died b e fo re sh e was six. Sh e had never actually b e e n abused
at all, b u t h er b est girlfriend had, and sh e had em p athized so c o m ­
pletely with her that sh e later im agined that it had hap p en ed to her.
O ther clients r e m e m b e r an event th a t they read in a b o o k or saw in
a movie, b u t later forget th e sou rce and think it hap p en ed to them.
T here is a fam o u s case o f this type— Bridey M u rp h y (Bernstein &
Barker, 1989). U nd er h ypnosis sh e recalled living in Ireland in a previ­
o u s lifetime. S o m e p eople checked h er description o f th e Irish village
 T h e N e w H andboooi-C qgnitiye. Therapy Techniques
56

HANDOUT: SELECTIVE M EM O RY

W henever you start reminiscing about your past, about the great
experiences you had in high school, about your first love or about
the wonderful time you had living in Akron, Ohio, you had best be
careful, because your memories may be fooling you. You may have
created a fantasy that never existed because you selectively screened
out all of the contrary themes, emotions, and experiences that did
not fit with the mood you w ere trying to strike. Fooled by this distor­
tion and taking it for the truth, you experience this fabricated past as
real.
Sometimes your distorted memory of the past creates your present
unhappiness. In such cases, the only w a y to become content in the
present is to force yourself to remember the past more accurately.
Only if you recall your history in the most unbiased, unprejudiced,
dispassionate manner will the lessons of your early experiences be
able to guide you.
It is best to choose your past carefully.

%
Finding the Beliefs 57
/

and fou n d h er reports to b e am azingly accurate. H er case was used as

ev id en ce for reincarnation. Later a reporter discovered that sh e had
learned th ese stories from an elderly w o m a n w h o had lived in the Irish
village as a child. W h e n Bridey was five she had sat o n the old
w o m a n 's porch and listened to the old w o m a n 's stories ab o u t Ireland.
Clients h av e b e e n tak en b a ck to th eir pasts b y using age-reg ressio n
hypnosis. T hey h av e revealed the details o f so m e earlier events, such
as a b irth d a y party at age 7, or th e first tim e th ey m et a future spouse.
U n d e r h yp n osis th ey reported the ev en ts in great detail, and were sure
that th eir recall was accurate, b u t w h en their m em ories w ere checked
against o b je ctiv e data such as photographs, diaries, or relatives'
reports, th e recall was found to b e grossly inaccurate.
A client, Diane, r e m e m b e re d h e r first m arriage with great fondness.
S h e had b e e n m arried fou r times, an d sp o k e ab o u t h ow kind, h a n d ­
s o m e an d strong h er first h u sb a n d was. Sh e spent years regretting the
loss o f th e relation sh ip an d kept trying to find him. This regret had
o n ly b e g u n after h er fourth m arriage was failing; b efo re that tim e she
h adn't th ou gh t a b o u t him at all. W e checked w ith so m e o f h er old
friends and fou n d out that h e r first h u sb an d had b e e n a horror. He
d ra n k m u c h o f th e tim e, ch ea ted on h e r constantly, could n't hold
d o w n a jo b for m o re th a n a few m onths, w ould n't c o m e h o m e for
days, an d physically a b u sed her.
How could s h e have failed to r e m e m b e r all o f this?
W h e n h er fou rth m arriage was failing, she had tried to com fort her­
self b y recalling at least o n e g o o d relationship in h er life. Since she
h a d n 't had one, s h e created o n e in her m em ory. Sh e recalled o n ly the
few g o o d th in gs a b o u t her first h u sb a n d and had totally forgotten the
m a n y b a d things.

C om m en t
M em o ry w'ork may b e traum atic for clients because o f the powerful
em otion s that are often associated w ith earlier experiences. In the begin­
ning stages o f cognitive therapy, the purpose is only to collect memories
rather th a n to ex a m in e them carefully or attempt to change them.

Further In fo r m a tio n
M a rk W illiam s (1996a, 1996b) is o n e o f th e m a jo r a u th o rs e m p h a ­
sizing th e im p o rta n c e o f m e m o r y in cognitive th e r a p y He b road en s
58 T h e N e w H andbook .o f . Co g nitive T herapy T echniq ues

the co n ce p t into four types: fact, b eh av io ral, event, an d prosp ective

m em ory. O u r em p h a sis here is m ost sim ilar to w h a t h e calls se m a n tic
m em ory, w h ere "d am ag in g e x p e rie n ces create v u ln e ra b le attitudes
a n d assu m p tion s that b e c o m e en co d ed as laws o f n a tu re in se m a n tic
m em o ry " (Williams, 1996b, p. 111).
Biases in selective m e m o ry h av e b e e n sh o w n w ith p an ic disord er
(Cloitre, Shear, C ancienne, & Zeitlin, 1994; McNally, Foa, & D onnell,
1989), so cia l p h o b ia (Lundh & Ost, 1997), g e n era liz ed a n x ie ty
(M acLeod & M cLaughlin, 1995), and depression (Beck, 1975, Beck,
Rush, Shaw, & Emery, 1979). A g o o d research review is S y m o n s and
Jo h n s o n (1997).

A t t r ib u t io n

--------------------A --------------- 1----------- Ce ----------- Cb ---------------►

B
attribution

Principles
A very im p o rtant cognition appears n ext o n th e tim elin e— a ttrib u ­
tion. The Latin root o f the word reveals its m ean in g : A ttribu tion co m es
from the past participle o f attribu m , m ean in g to b esto w o r assign. This
is w hat clients do to the perceptual w orld th ey ex p erience. They
bestow or assign causes and effects to w hat they sense. They n eith e r
find nor discover causes; th ey create them . They guess at th e cause o f
alm ost every ev en t that th ey experience. Their attrib u tion m ay b e
totally w rong— it m ay b e a superstition and have n o th in g to d o w ith
th e real cause— b ut th ey will c h o o se o n e just th e same.
O u r clinical ex p erien ce suggests that m ost clients pick th e w ron g
cause m ost o f th e time. W h e th e r they're search in g for th e cause o f
their p anic attacks, w h y th ey go t divorced, w hy th e y can 't h an d le
alcohol, or why they keep returning to a m ental hospital, m ost
patients m isattribute th e cause and c o n se q u e n tly m isd irect th eir activ­
ities to solve the problem . O n e o f th e aim s o f cognitive restructuring
therapy is to help clients ferret ou t real causes from superstitious ones.

M ethod
1. Focus o n clients' particular i\ -C situations.
2. W h at do th ey b elieve are th e causes o f th e problem s?
Finding, the Beliefs S9
/

3. H ave th em use th eir im a g in a tio n an d picture all th e o th e r possible

causes they can th in k of. Practice u ntil they e a c h can m a k e a large
list.
4. Help th em lo o k for th e o b je ctiv e ev id en ce b o th for and against each
ca u se o n th eir list. Pick th e cause th a t has the m ost positive and
least n eg ativ e evidence.

E x a m p le
A ttribu tions are a crucial B, and they m a k e an im p o rta n t difference
in h ow ev en ts effect clients. A ttribution is the difference betw een
w h e th e r clients ju d g e th em selv e s resp o n sib le for their b e h a v io r or
not.
Im a g in e a m a n driving d ow n a street late at night. A teenage b o y
su d d en ly ru n s into th e road from b e h in d so m e buses, th e m an slams
o n his brakes, b u t it is too late; h e can't stop and hits th e boy, killing
him . W h e th e r this m an is guilty o f m u rd e r or an u n fo rtu n a te partici­
pant in a terrible accid en t is totally d e p en d en t u p o n th e m otive that
a ju ry attributes to him. If th ey b eliev e that h e did everythin g h e could
to avoid the accident, they will rule h im in n o cen t. If they th in k he
steered his c a r into th e b o y and tried to hit him, th ey may convict him
o f murder. If h e was drin king alcohol they m ay ju d ge him guilty o f
m anslaughter, a type o f in -b e tw e e n guilt. No m atter w h a t the jury's
attrib u tion, the ev en t rem ain s th e same, the b o y is dead and th e m an
killed him. But w h at will h a p p e n to th e man, w h e th e r h e spends the
rest o f his life in prison or is im m ediately released, is d ep en d en t u p on
th e ju ry's attrib u tion and their attrib u tion alone.
In a sense, clients are all a m a te u r jurors. T hey lo o k at their
responses, n otice w h a t h a p p en ed ju st b efo re they acted, and guess
a b o u t th e cause. T hey d o th e sa m e w h e n look ing for exp lanations for
others' behavior. U nfortunately, p eople are often p o o r jurors, and their
gu esses are o ften w rong. People rarely take steps to distinguish real
causes from ra n d o m coin cid en ces. W h a te v e r ex p la n atio n ju m p s into
their m ind s initially is o ften w h at th ey ju d ge is th e cause, and they
rarely lo o k further. M ost o f the time, their attrib u tions c o m e from
so m e private su p erstition s th ey h av e never investigated.

C om m en t
M a n y clients are strongly insistent that th eir attrib u tions are cor­
rect. T h ey vig orou sly assert that th ere is n o o th e r possible cause.
W h e n the th erap ist asks, "H ow can you b e so sure?" T hey answer, "I
60 T h e N e w H andbook of Co g nitive T h erapy T echniq ues

ju st kn ow it." T h ey are very relu ctant to use a n y rational o r em p irical

process to e x a m in e o th e r possibilities.
A direct attack b y therapists against th ese assertion s u su ally fails.
Clients sim p ly assu m e that th e therapist is w rong, d o e sn 't u n d ersta n d
th e situation, o r w asn 't there and has n o w ay o f kn ow ing. A m o re
effective a p p roach is to dep erson alize th e search for causes b y h a v in g
clients discover o th e r ex p la n a tio n s for them selv es (see a lternative
interpretation section in ch a p ter 6).

F u rther In fo r m a tio n
For tw o c o m p reh en siv e b o o k s on th e attrib u tion process, see G ra­
ham an d Folkes (1990), and Kelley (1972). A ttribu tion is related to th e
words clients use— particularly th e v erb s th ey c h o o s e — to d e scrib e
events. S ee C heng and Novick (1990), C orrigan (1992), Rudolph and
Forsterling (1997) fo r a m o re c o m p re h e n siv e ex p la n a tio n o f th e c o n ­
nection b etw een lan gu age and attribution.
An excellent stu d y b y Linda B o b b itt d em o n stra tes th at a ttrib u tio n a l
style is n ot a personality trait b u t ra th e r b ased o n th e c o n te x t o f dif­
ferent situations. T he results o f h e r studies indicated that p eople
attribute differently d e p en d in g u p o n w h e th e r th e situ atio n is social or
co m p e titiv e in n atu re (Bobbitt, 1989).

E v a lu a t io n s

-------------------- A ------------ Ce — I— Cb --------------- ►

B
ev alu ation s

P rin ciples
This tim elin e show s a separation b etw e en the e m o tio n (Ce) and th e
b e h a v io r (Cb). M o st clients d o n 't recognize this d isju n ction . T h ey
a ssu m e that o n c e th e y feel an e m o tio n a b e h a v io r a u to m a tica lly and
in stan ta n eo u sly follows. T h ere are, however, at least th ree types o f
c ogn ition s in terv en in g b etw een feeling s o m e th in g and acting o n it.
First is th e client's cogn itiv e e v a lu a tio n o f th e em o tio n . W h e n e v e r
clients feel scared, sad, o r angry, th ey im m e d ia tely ju d g e h ow b a d th e
feeling is; they appraise w h e th e r th e e m o tio n is m ild and m a n a g e a b le
o r horrib le and catastrophic. «
Finding th e Jk lie fs_ _ _ _ _ _ _ _ _ _ 61
/

The intensity o f a n y em o tio n is in part d e p en d en t u p o n how it is

cognitized. S o m e clients ex ag g erate ev ery em otio n . They tell th em ­
selves, "It is terrible that I a m tense. I can't stand feeling sad. It is h o r­
rib le th at I get frustrated." All o f th ese negative em o tio n a l evaluations
crea te a n e x trem e ly low frustration tolerance. If clients tell them selves
th at they c a n 't stand som ethin g, this b e lie f will keep th em from w ish­
ing to to lera te th e feeling. It is not b eca u se th ey could n't stand it, but
sim p ly b e c a u s e th e y told them selv es th a t they w ould n't b e a b le to. If
clients tell th em selv es that th ey can't en d u re b e in g ten se o r scared,
th e y may, u p o n feeling th e slightest tinge o f tension, try to escap e
from th e A in o rd e r to rem o v e th e feeling th ey h a v e ju d ged as a h o r­
rible, terrible, and catastrophic. If th ey tell them selves it is distressing
to feel ten sio n b u t not d angerou s, or that it is u n fortu n ate to b e sad
b u t n o t horrible, o r th at it is displeasing to feel a n n o y a n c e b u t not
appalling, th en th ey will feel upset b u t will not en g age in any extrem e
b eh av io rs.
A lb ert Ellis, the g ra n d fa th er o f all cogn itive therapies, distinguishes
b e tw e e n tw o types o f ev alu ation s (Ellis, personal co m m u n ica tio n , M ay
2, 1986). He states that clients can ev alu ate em o tio n s eith er rationally
or irrationally, an d that this d eterm in es h ow they are m otivated to
c o p e w ith th e A. Rational ev alu ation o f e m o tio n includes frustration,
sorrow, a n n o y a n ce , regret, an d displeasure, and may range o n a scale
o f in ten sity from 1 to 99. T h e irrational ty p e o f evaluation b eg in s at
101 an d g o e s to infinity. E m otio n s su ch as depression, anxiety, rage,
despair, hostility, and self-pity fall on this scale. This typ e o f evalua­
tion causes th e p ro b lem s for clients b e c a u s e th ey h av e created e m o ­
tions w ith ou t limit; they h av e turned regret into despair, fear into
terror, a n n o y a n c e into rage. To solve this self-created problem , clients
h a d b e st practice co u n tercatastrop h izin g and bring th eir evaluations
b a ck in to the w orld o f norm al limits.

M eth o d
1. Help clients m a k e a list o f ten ev en ts from their past that greatly
upset them.
2. H elp th em to record o n a c o n tin u u m from 1 to 7 how upset they
w ere a b o u t th e event. O n this c o n tin u u m , th e ev en t is rated a 6.
dam age upset

slightly u p s W 3 4 hOTrible & terrible

62 T h e N ew H andbook of Co g nitive T herapy T echniq ues

5. Next, have clients record oil th e c o n tin u u m h ow d a m a g in g the

ev en t actu ally turn ed o u t to be. This c o n tin u u m show s a ratin g o f
2.
4. The difference b e tw e e n th e tw o scores is h o w m u c h y o u r client c a t -
astrophizes. (+4).
5. Rem ind y o u r clients th at th e n ex t tim e th ey are upset th ey w ould
d o well to r e m e m b e r h ow m u c h th ey e x a g g era te and practice
a d ju stin g th eir fear to a m o re realistic level.

E x a m p le : T he Story o f Betsy
Clients' ev alu ation s o f e m o tio n s so m e tim e s b e c o m e so tw isted th at
they can ch an g e a positive e m o tio n into a negative o n e ju st th ro u g h
their thinking. An ex a m p le is th e case o f Betsy.
Betsy w as a y o u n g stu dent in h e r first y e a r o f college. S h e visited
m e w h en I was a therapist w o rk in g in a college co u n selin g center. Sh e
told m e that strong em o tio n s w ere o v e rw h e lm in g her. S h e cou ld n 't
describe exactly w h a t sh e was feeling, since s h e had n ev er felt th ese
em o tio n s before, b u t sh e was terrified o f th em . Sh e felt very u p set and
th ou g h t sh e cou ld n 't c o p e a n y longer; s h e feared losing h e r m ind. Her
feelings had started a few m o n th s earlier, right after sh e h ad arrived
o n cam p u s as a freshm an.
We searched for a cause b y exp lorin g h e r back grou nd . Betsy h a d an
u n u su a l history. Her m o th e r and father w e re severely h a n d icap p ed
th ro u g h o u t th eir lives, b u t s h e was not. A lthou gh h e r parents' severe
hand icap s limited their activities, sh e d escribed th em as w a r m and
caring, and said th a t she'd had an o th erw ise n o r m a l and positive
childhood.
Finding n o th in g in h er past, w e exp lored th e present. H er college
e n v ir o n m e n t was satisfactory. S h e lived in the d orm s w ith a friendly
room m ate, was p o p u lar w ith h er fellow students, had g o n e o n several
dates, and en joyed social fu n ctio n s o n cam pus. Sh e w asn't hom esick,
h e r parents w ere pleased sh e had g o n e to college, an d h e r b r o th e r and
sisters to o k care o f h e r parents so sh e felt n o guilt a b o u t leavin g hom e.
Sh e viewed her classes realistically, was an ex cellen t student, and
found th e courses interesting b u t not to o difficult. Sh e h a d n o m e d ­
ical problem s.
W e searched a n d searched b u t ev eryth in g seem ed to b e fine. This
attractive yo u n g lady was doing well in school, h a d friends, no p ro b ­
lem s at h o m e , had lived successfully aw ay from her paren ts for se v ­
eral m onths, b u t felt su d d en ly attacked b y o v erp o w erin g feelings sh e
Finding the Beliefs .63
/

co u ld n 't con trol. W h a t was ca u sin g h e r to b e so upset?

O u r discu ssion o f e v alu atio n provided the answer. H er p rob lem was
not w ith her e m o tio n s b u t with th e way sh e evaluated them. A ny o f
h e r ev a lu atio n s c o u ld h av e b e e n the problem , but only o n e turned
ou t to b e crucial.
Sh e h a d ev alu ated h e r upset e m o tio n s in th e sa m e way that I had,
and had assu m ed, as m ost p eople would, that the co re em otio n
u n d erly in g ev ery th in g m u st h a v e b e e n negative. M ost o f us would
a ssu m e that the h orrib le and ca tastro p h ic feelings Betsy described
w ere anxiety, depression, guilt, anger, or so m e o th er aversive state.
T h ese are th e e m o tio n s th at b o th e r us, so we naturally con clu d e that
th ese m u st h av e b e e n th e e m o tio n s b o th e r in g Betsy. But w h en 1 tried
to resolve h er presum ed negative em o tio n th ro u g h relaxation train­
ing, su p p o rtiv e counselin g , and desensitization, it didn't work. It was
o n ly later that I discovered that the em o tio n s that scared h er weren't
negative at all— th e y were positive!
Stran g e at it m a y sou nd, Betsy had evaluated h e r happ y feelings as
negative. B ecau se o f th e w ay she had b e e n b rou g h t up an d th e time
s h e had sp en t takin g ca re o f her h an d icap p ed parents, she'd never
en jo y e d h e r youth. She'd had few friends b ec a u se o f h er h ou sehold
responsibilities, h ad n 't dated, an d had n ev er d o n e things just for the
fun o f it. H er life hadn't b e e n negative, b u t it had b e e n im m ensely dull
and deprived o f ex citem en t. Because Betsy had no parallel life to c o m ­
pare hers with, sh e h adn't k n ow n that life could b e fun. Now, after a
few m o n th s o f college, sh e w as b e in g b o m b a rd e d with s t i m u l a t i o n -
n ew friends, success in school, dating. H er ex cite m en t was so new and
u n ex p ec ted th a t it felt terrifying. H aving rarely experien ced excite­
m e n t before, sh e didn't kn ow h o w to c o p e with it; it was so new and
so u n e x p e c te d th a t sh e panicked.
S o lv in g her riddle helped solve h e r problem . Instead o f helping
Betsy to su ppress h e r em otion s, w e taught h e r to accept them. Sh e was
sh o w n th a t e x c ite m e n t is a pleasure to b e enjoyed rather than a ter­
ror to b e avoided.

C om m en t
M ost clients' ev a lu atio n s o f their em o tio n s are subtle. T h ey place
twists an d spins o n their e m o tio n s that keep th em from cop in g with
their feelings. O v e r th e years, I h a v e heard th e following twists.
"I sh ou ld n 't feel th is way!'
"It's w ron g th at I have to feel this."
64 T u t N e w H andbook or Cognitive T herapy T ech n iq u es

"It's d a n g ero u s to feel."

"I shou ld b e a b le to co n tro l this e m o tio n and m a k e it g o away?'
"If I don 't get rid o f this feeling, it will take o v er a n d co n tro l
me."
"I can't stand this feeling."

F u rther In fo r m a tio n
Ellis a n d th e rational em o tiv e b e h a v io r therapists are th e m a jo r
grou p o f c o u n selo rs that h av e em phasized th e im p o rta n c e o f clients'
evaluations. Ellis's w e ll-k n o w n p h rase o f "terrible, h orrib le, c a ta ­
strophic," represents clients' m istak en e v a lu a tio n o f th e d a m a g e o f an
em otio n . See Ellis (1962, 1985, 1988a, 1995, 1996; Ellis & Dryden, 1996;
Ellis & Harper, 1961, 1971, 1975, 1998; Ellis & Lange, 1995; Ellis, G o r­
don, Neenan, & Palmer, 1996; Ellis & Tafrate 1997; Hauck, 1994).
Extrem e ev alu ation s o f social situ atio n s are th e key to social fears
and social ph ob ias (see th e review article o f H eim berg & Juster, 1995).

S e l f -I n st r u c t io n

-------------------- A ------------ Ce — I— Cb --------------- ►

B
self-in stru ction

P rin ciples
The second b e lie f that occu rs b etw e en the e m o tio n (Ce) a n d th e
b e h a v io r (Cb) can also o c cu r a n y w h e re o n th e tim eline. I call this B the
in n e r teacher. Clients d e scrib e this co g n itio n as havin g an o n g o in g
dialogue with them selves, as if they h a d a n a d v iser inside th eir h ead s
talking to them . This in n e r voice m a y b e lou d or soft, in tru siv e or in
th e back grou nd , b u t w h en clients pay atten tion to it th ey ca n usu ally
h ear it. O n e client d escribed it as, "like h a v in g y o u r ow n private tu to r
inside y o u r head."
M o st clients report that they can carry o n a long, involved d ialo gu e
with them selves a b o u t w h at th ey sh ou ld d o w h en th ey feel scared, get
angry, o r feel depressed. T h eir te a c h e r sp eaks to th e m b e tw e e n the
em o tio n and b e h a v io r and m a y tell th e m to ru n away, hit som eb od y ,
o r pretend that n o th in g has happ ened .
Finding the. Beliefs 65
/

O th e r tim es, th eir in n e r v o ice focu ses o n so m eth in g totally differ­

ent, like telling th em w hat to eat for dinner, rem in d in g th em to tune
up th eir c a r o n Saturday, o r b e ra tin g them for having erred o n a b u si­
ness project. Clients h av e a s tr e a m -o f-c o n s c io u s dialogue goin g o n all
o f th e tim e, ev en during th e co u n selin g session. They don't o ften m e n ­
tion it o r reveal its contents, trying instead to narrow th eir responses
to th e therapist's q u estio n s o r to th e direction o f the therapy session.
S o m e tim e s it is useful to h a v e them report on this o n g o in g dialogue
(th e v o ice inside th eir head). Reassure you r clients that having an
in n e r d ialo gu e isn't a ca u se fo r concern. Everybod y has a v o ice or
in n e r teacher. A lth ou gh they can focus their atten tion o n o n ly one
ta sk at a tim e (like listening to you), their b rain still processes o th er
u ndigested thoughts, images, and experiences. It's like having two
c o m p u ters g o in g at o n c e — o n e listening to you and th e o th e r th in k­
ing a b o u t o th e r things. It's n o rm a l for everybody, b u t this ongoing
d ialo g u e can reveal so m e key attitudes that th e client has not dis­
cussed.

M eth od
1. P eop le co n sta n tly h av e an internal d ialo gu e with them selves. They
talk to th em selv es continuously, giving advice, m ak in g evaluations,
trying o u t n ew strategies, and teach in g new principles. To access
this o n g o in g dialogue, therapists can em p loy Aaron Beck's princi­
ple o f a u to m a tic thoughts.
2. Tell y o u r clients th a t w h en th ey are n ot d o in g an y th in g in particu­
lar th e y sh ou ld focus o n th eir autom atic, internal chatter. Have
th e m write dow n w h at th ey are thinking. Or, if they need help, you
can w rite it dow n w ith th e clients in o n e o f you r sessions. You need
to c o n tin u e to p ro b e past th e first few responses to allow all o f th e
th ou g h ts to em erge. Tell clients not to report in the way th a t th ey
u su ally do. D on't try to m a k e c o m p le te se n te n ces or keep irrele-
v an cies or distractions out, don't c e n so r th e th ou g h ts for g ra m m a t­
ical o r personal reasons. H ave them write dow n ev eryth in g exactly
as the a u to m a tic th o u g h t occurs.
3. Ask th em to put th eir writing aw ay for a few days and bring it to
y o u r n ex t session. Help th em relate th eir writings to th e core
th ou g h ts th at you have gathered.
4. Keep clients' s p o n ta n e o u s writings. T hey will provide you with a
g o o d s n a p sh o t o f their internal processing.
 T he N ew H andbook of Cognitive T herapy T echniq ues

E x a m p le
Clients often h a v e n a sty voices talking to them . O n e client had a
vo ice like Cinderella's stepm other. It kept yelling, "You stupid, lazy
slob! You haven't d o n e a n y th in g with y o u r life. You h aven 't h a d a rela­
tionship w ith a m an that's a m o u n te d to an ything . W h a t a rotten piece
o f garb age you are and always will be."
A n o th e r client h ad a te a c h e r so m e a n that w e called it, "T h e Nazi in
H er Head." It w ould cruelly attack h e r for th e slightest m istakes. I su g­
gested that sh e fire th e old teach er and hire a new one.
A m illionaire b u sin essm an client had a v o ice that w ould n e v e r let
him succeed. It kept shou ting, "You th in k you 're G od's gift to the
world b ec a u se y o u 're rich, don 't you? Well, you aren't an y th in g . You
can m a k e all th e m o n e y in th e world, b u t y ou will alw ays b e a class­
less bum."
A lth ou gh m a n y p eople have nasty teachers, n ow and th e n th era ­
pists c o m e across an in n e r voice that is to o kind. G eorge, a heroin
addict, had a teach er that w as a cross b e tw e e n P o lly a n n a a n d a Little
Sister o f the Poor. It w ould tell him , "D on't w o rry a b o u t th o s e n a sty
old cops arresting you for hold in g up a liq u o r store again. It’s n ot y o u r
fault; it's ju st th a t you had a b ad ch ild h ood . D eep d o w n inside you are
still a g o o d boy, p o o r dear/' W h a t he really n eed ed w as a te a c h e r with
th e te m p e ra m e n t o f a M a rin e drill sergean t w h o w ould k e ep h i m in
line and m ak e him face all th e m isery h e had inflicted o n others.

C om m en t
W h e re do clients' in n e r teachers c o m e from ? How do th ey pick
th em ? M an y clients can identify th e source. T h ey o ften recognize th e
teacher's to n e o f v o ice an d can picture a person sp eak in g to them .
So m etim es they h ear a parent or o th e r relative, o r th ey picture a
sch o o l teacher, doctor, or coach th ey o n c e knew. O th er tim es they
im agine an historical figure like A be L in coln or a literary c h a ra cter like
Hector. Pread olescent children- pick fa n ta sy figures su ch as Jo h n n y
Quest, or Su p er Friends: W o n d er W o m an , Su p e rm a n , an d A q u a m a n
(Me M ullin, 1999). W h y p e o p le c h o o s e o n e tea ch er o v er a n o th e r is still
not clear. T h e in n er tea ch er is u su ally c h o se n at an early stage o f life,
p ro b a b ly preadolescence. This is su ch a tra u m a tic tim e for m ost p e o ­
ple th a t th ey feel th e need for gu id ance, an d if it isn't a v ailab le from
the ou tsid e th e y crea te th eir ow n from th e inside. A b o y w h o feels
w eak o ften creates a R a m b o -lik e te a c h e r to m a k e h im strong. This is
Finding the Beliefs
/

his m ind 's w ay o f tea ch in g him w hat h e thinks h e needs to learn in

o rd e r to b e tough. A b o y w h o w ish es to please his father but feels he
isn't su cceed in g m a y b rin g his fa th er inside his ow n head to give him
private instruction. An ad olescen t girl w h o feels lonely m ay create a
kind ly g r a n d m o th e r tea ch er to give h e r the em o tio n a l chicken soup
sh e wants.
T h ere is n o th in g w ro n g w ith p eople creating these teachers to help
th em w h en th e y are young. T he p rob lem occu rs w h en the client d o e s­
n't kn ow w h en to retire the tea ch er and hire a new one. T h e heroin
addict's soft tea ch er m ay h a v e b e e n helpful w hen h e was little b ecau se
h e grew up in an a b u sin g fam ily and needed to create a caring per­
so n to help h im c o p e w ith a hostile, u nloving world; the nurturing
in n e r v o ice h elp ed h im then. But w h e n G eorge b e c a m e addicted to
h ero in h e n eed ed a different voice— a tough, streetw ise gu ide who
c o u ld help h im fight a serious drug addiction. This was b ey o n d his
kind ly g r a n d m o th e r teacher, b u t h e n ev er fired her; sh e had tenure.
W ith the therapist's help, clients can replace their teachers. O ne sign
th at therapy is su cceed ing is a client's report that a different voice is
advising. In m ost cases b ad voices are replaced b y g o o d ones. New
teachers start to say things like, "You didn't succeed, b u t it w as a goo d
try?' "I kn ow you feel bad, b u t hold on; it will pass." "Keep w orking on
it, you'll m a k e it."
O n e client replaced his G enghis K h a n -ty p e tea ch er w ith a group o f
wise elders. O n e w as a Buddhist m onk , a n o th er was Albert Schweitzer,
and th e third was his kind ly old g ran d fath er w h o m he had hardly
know n . W h e n e v e r h e felt sad, h e closed his eyes, relaxed, and im ag­
ined th o se th re e p eople sitting with h im and giving him advice. They
w ould so m e tim e s d e b a te a b o u t what h e shou ld d o and he would
so m e tim e s argu e back, but h e felt that they cared for him and h e u su ­
ally fo u n d th eir advice useful.
Clients don 't really have a tea ch er inside; the v o ice they h ear is their
own, o r at least a n o th e r part o f th eir ow n brain. If th ey h ear a nasty
v o ice th ey had b est get rid o f it— if it's a g o o d teach er giving wise
advice, th ey sh ou ld listen.

F u rth er In fo r m a tio n
Tracking a u to m a tic th ou g h ts was m ad e fam o u s b y Aaron Beck. He
d ev elo p ed ex ten siv e proced ures for c o u n tin g them , h elp in g clients
d ev elo p an a w areness o f th em and shifting them (see A. Beck, 1975,
1993; Alford & Beck, 1997; and J. Beck, 1995).
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The N ew Handbook or Cognitive T herapy T echniques

A m a jo r c o n trib u to r to th e c o n ce p t o f client se lf-in stru ctio n is Don

aid M e ic h e n b a u m from T h e U niversity o f W aterloo in C an ad a (see
M e ic h e n b a u m 1975, 1985, 1993).

Th e H id d en C o g n it io n

-------------------- A ------------ Ce — I— Cb --------------- ►

B
hidden b e lie f

P rin ciples
T h e third cogn ition b etw e en e m o tio n an d b e h a v io r is a b e li e f I call
th e hidden cognition. It is hid d en b e c a u s e m o st clients are n o t aw are
o f its existence. T he B occu rs after clients feel a n em otio n , b u t im m e ­
diately b efo re they en g age in a b e h a v io r (b e tw e e n Ce a n d Cb). M ost
clients don 't notice this co g n itio n b e c a u s e it is so rapid. T hey ex p e ri­
en ce it as a vag ue im pression, an u n d igested co n ce p tio n often o c cu r­
ring b efo re they can put it into words. T h o u g h short, it can b e v ery
powerful.
W h a t is this B?
It is an in stan ta n eo u s decision to carry a feeling th ro u g h to a
behavior, like a non lin g u istical w h isp er in w h ich a client thinks, "Yes,
I should," or "No, I shouldn't."
M o st clients d e n y h a v in g this cognition. T hey b e lie v e th at th ere is
no b reak b e tw e e n feeling an d acting, a n d th a t o n c e th e y feel s o m e ­
thing th e em o tio n im m ediately forces th em to ta k e a specific action.
They su p p o se th a t th e y have n o c h o ic e b u t to act. A ccord ing to th e A -
B -C form ula, this is like asserting th a t e m o tio n s at Ce ca u se b e h a v io r
at Cb. Clients usually say so m eth in g like, "I got so scared 1 h ad to ru n
away;' "Becau se 1 felt so depressed, 1 cou ld n 't get o u t o f bed," or "I felt
so angry that I had to hit him."

M eth o d
1. Ask y o u r clients to focus o n th e last tim e th at th ey acted im p u l­
sively. It is th e behavior, n o t the th o u g h t o r em o tio n , th a t you are
look in g for. Pick a tim e w h ere th ey sla m m ed a door, o r cursed at
so m eo n e, o r ran away from so m e danger.
Finding the Beliefs
/

2. Help y o u r clients search th ro u g h their m em ories to see if they can

find th o s e in sta n ta n e o u s th ou g h ts a n d key cogn itions th a t gave
th em p erm issio n to act. S o m e possible th ou g h ts you m ay find:

1 m u st express m y feelings.
I can 't co n tro l it.
It's th e right th in g to do.
1 ca n get aw ay w ith it.
I a m n o t responsible; so m e th in g m ad e m e do it.
I sh o u ld d o it.
I h av e to do it.
I can't keep from d o in g it.
I w an t to d o it.

3. Focus o n o n e o f y o u r client's thou ghts and switch it to see if you

h av e found th e right cognition. H ave y o u r clients im ag in e that they
b elieved the op p o site thou gh t. Get th em to picture the scen e as
v iv id ly as th ey can. T h en ask them, "W ould you have b e h a v e d in
that way if y ou b elieved this opp osite thou ght?" If the answ er is no,
th e y w o u ld not h a v e eng aged in th e behavior, th en you h av e found
their h id d en cognition.

E x a m p le
T h e clients w h o p ro b a b ly d e n y the hidden cognition most fre­
q u e n tly are the b a tte rers— m e n w h o assault their wives or girlfriends.
"Sh e m a d e m e so angry that I hit her." T he m an is asserting that his
feeling o f a n g e r (Ce) directly caused him to hit the w o m a n (Q,). He is
claim in g th at h e had no ch o ice in th e m atter— th a t it hap p en ed
against his will. It's sim ilar to claim in g tem p orary insanity, o r saying
"th e devil m a d e m e do it." He denies th e existence o f a cognition that
o ccu rs b e tw e e n his feeling and his action.
This claim is a n in accu rate assertion. Em otion s don't m ak e clients
act in a certain way. T hey m a y inclin e p e o p le to act, they m ay m oti­
v ate them , b u t th ey don 't m a k e th em respond. Betw een the em otio n
a n d th e action th ey tell them selv es so m eth in g ; they m ak e an asser­
tion. This assertion m ay b e a lm ost in stan taneou s. T h ey are probably
n o t aw are o f it, b u t it is th e re nevertheless. The b attering m a n may
assert to himself, "Yes, I can," o r "Sh e can 't stop me," or "Sh e deserves
it," o r "It will feel g o o d to hurt her," o r "I can get away with it and n o th ­
ing b ad will h a p p e n to m e i f I do." W h a tev e r his assertion is, after he
 T h e N e w Hand bo o k of_ Co g n it iv e T herapy T echniques

gets angry and b e fo re h e hits' his wife h e gives h im s e lf s o m e sort o f

perm ission to g o ah ea d and do it, an d th e therap ist can usually id en ­
tify that b r ie f cognition.
W h at assu rances d o w e h av e that this co g n itio n exists? H ow c a n we
b e sure th ere are intervenin g th o u g h ts b e tw e e n clients' feelings and
clients' actions? T he e v id e n ce is th a t clients can act in to tally different,
often contrad ictor}' w ays w h ile im m e rse d in the s a m e feeling state.
T h e b attering h u sb a n d w h o claim s his a n g e r m a d e h im h it his 5'2",
1 1 0 -p o u n d wife will not take a sw in g at a 6'5", 2 8 0 - p o u n d arm ed
p o lic em a n w h o is investigating th e assault. He m a y b e e v e n angrier
with th e officer for interfering in his d o m estic m atter th an h e was with
his wife, b u t his an ger will not reach fruition. W h y ? If his e m o tio n
causes th e behavior, sh ou ld n 't h e attack th e officer^
The a n sw er is that his cognition, his self-assertion , w as different in
th e tw o situations. W ith his wife h e m a y have told himself, "She's lit­
tle. Sh e can't h u rt me. N othing h a p p e n e d th e last five tim es I hit her."
But w ith th e officer, h e m ay tell himself, "He could b e a t the hell o u t o f
me. M a y b e I'd b etter cool it." It is n o t surprising how easily clients can
keep their e m o tio n s from lead ing to certain b e h a v io rs w h e n the
b e h a v io r m ay b e severely and in sta n ta n eo u sly punished.
A n o th er e x a m p le o f p eople w h o don 't b e lie v e in th e h id d en B are
addicts. M a n y c h e m ic a lly -d e p e n d e n t clients b e lie v e th at u n p leasan t
em o tio n s drive th em to u se drugs. T h ey say, "I felt so depressed, angry,
o r scared I ju st h a d to take a drug to feel better.” T h ey b la m e th e e m o ­
tion fo r m aking th em use.
W e h av e told addicts that b elie v in g that e m o tio n s drive th e m to use
is an excuse, a se lf-c o n (Me M u llin & Gehlhaar, 1990a). Em otions, no
m atter h ow strong o r intense, don 't drive a n y b o d y a n y w h ere, m u ch
less to a b u se drugs. Em otions don 't k n o w h ow to drive; th e y ju st sit
there and b u b b le. Addicts d o n 't c h o o s e to b e addicted, b u t th ey d o
ch o o se to take drugs, c h o o s e to g o alon g w ith th e craving, c h o o s e to
respond to th eir e m o tio n s b y taking a drug. Addicts h a v e a hidden
cogn ition that occu rs b etw e en th e cravin g a n d th e using. T h e c o g n i­
tion takes the craving an d turns it into action. If the h id d en c o g n itio n
is changed , n o actio n will occur. T he recovering a lc o h o lic w h o says,
"No," to his craving will not drink. T h e assertive m a n w h o says, "No, I
w o n ’t hit her," will not strike his wife n o m atter h ow greatly h e is
angered. People m ay not b e resp on sib le for feeling an e m o tio n b u t
they are resp on sib le for actin g o n it. Feeling m a y b e an a u to m a tic or
co n d itio n e d reflex, b u t actio n c o m es from o u r ch oices an d past rein ­
forcem en ts rath er th an o u r reflexes.
Finding the Belief's
/

C om m en t
It m a y seem th a t the q u e stio n a b o u t em o tio n s cau sin g b e h a v io r is
o n tolog ical a n d b etter answ ered b y p hilosop hers argu ing a b o u t free
will and d eterm inism , o r b y lawyers argu ing culpability in a court­
ro o m . But as therapists w e are faced with clients trying to free th em ­
selves from destructive b e h a v io rs that are destroying their happiness.
W e don 't need to an sw er th ese p h ilosop h ical-leg al questions, b u t we
d o need to help o u r clients stop their self-d estru ctive behaviors.
O n ly b y carefully ex a m in in g your clients' cognitions will you confirm
that clients do h av e an intervening cognition after they feel but before
they act. Sim ply asking a client, "W hat did you tell yourself b efore you
hit y o u r se v e n -y e a r-o ld son?" will almost always get the sam e response:
"1 didn't tell m yself anything. I just got angry and hit him." If you ask
this client to im agine the scene in detail, h e will see the appearance o f
th e hidden cognition. Tell him to use all o f his senses until he feels
a b so rb ed by the scene. How did his son look? W hat were the other
sights and sounds? W h at did he feel? Then at the crucial point, sw'itch
the hidden cognition. If h e was thinking, "It is n o big deal. I didn't hit
him that hard," you should help him change his focus. For example, say:

In this situation, you w ere focu sing on y o u r ow n feelings o f

anger. This tim e im ag in e th e situation w hile focusing on you r
son's feelings o f terror. You can d o this b y rem em b erin g vividly
h o w you felt at the s a m e age w h en y o u r fath er hit you. Do you
recall h o w it felt? Take a few m o m e n ts and try to r e m e m b e r it.
G ood. Now im ag in e th e situ ation again, but this tim e feel you r
son's terror. Do you still feel it was n o big deal? Do you still
b e lie v e that you had no ch o ice but to hit him?

One final n o te : I have o c c a s io n a lly c o u n s e le d clien ts who

adam antly, consistently, and an grily den ied having a n y thou ght inter­
v e n e b e tw e e n their em o tio n and th e destructive b ehavior. T h ey claim
v e h e m e n tly that th e y w ere helpless victim s o f th eir u n con trolled pas­
sion. W ith o u t excep tion , w h en I learned m o re a b o u t the circu m ­
stances, I discovered th at th ey all had an external reason for their
denial. S o m etim e s th e reason was legal: "If I adm it to th in kin g so m e ­
thing, I will b e a d m ittin g I was responsible." So m etim es the problem
w as guilt: "It w ould b e m y fault." To help th ese clients accept their hid­
d en cogn ition, it was alw ays n ecessary to shift the rein forcem en ts until
the rew ards for accep tin g the cogn ition ou tw eig hed the rewards for
d e n y in g it.
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The New Handbook 01 Cognitive Therapy Techniques

F u rther In fo r m a tio n
H au ck (1980, 1991,1992, 1998) was o n e o f th e first writers to identify
the hidden cognition. Ellis (Ellis, M clnerney, D iG iuseppe, & Yeager,
1988) labels these beliefs as facilitive in th e sense th a t th ey facilitate
drug and alcohol use for th e addicted patient. A a ron Beck (1996)
agrees that there is an activation m o d e th a t m ay pred isp o se th e p e r­
so n to certain action.

E xpla n a to r y St y le

B
ex p la n a to ry style

P rinciples
T h e last B in the tim elin e follows th e o th ers cited earlier. After the
activating event occu rs an d clients h av e searched th e ir m em ories,
attributed a cause, and lab eled their feelings, after th ey 'v e ev alu ated
their feelings, advised them selves, and acted, clients form a c o n c lu ­
sion. T hey m ak e s o m e se n se o r m e a n in g o f the ev en t b y su m m a rizin g
the exp erience, telling them selv es w h y it h ap p en ed , and figuring out
w hat they can do a b o u t it in th e future. T h ey m a y say, "Well, th is just
proves w h a t a rotten person 1 really am," or th ey m ay con clu d e, "1 had
s o m e b a d luck this tim e a n d m a d e so m e m istakes, b u t I'll practice and
do b etter in th e future."
E m in e n t psy ch ologist M artin S e lig m a n an d his c o lle a g u e s d is co v ­
ered th a t people's e x p la n a tio n s a b o u t w h y b a d th in g s h a p p e n are
h ig h ly in d icative o f h ow th ey will c o p e w ith th e sa m e situ a tio n in
th e future. S e lig m a n d efined th r e e im p o r ta n t ty p e s o f e x p la n a to r y
styles: in te rn a l v e rsu s e x te rn a l; sta b le versus u n s ta b le ; g lo b a l v ersu s
specific. In d iv id u a ls w h o e x p la in n eg a tiv e e v e n ts w ith in tern al, sta ­
ble, or g lo b a l c o g n itio n s w e r e m o r e likely to get d ep ressed and
d e v elo p "learn ed h elp lessn ess" (S elig m an , 1975, 1994, 1996). T h e first
e x p la n a to r y style, internal, refers to th in k in g that b io c h e m is t r y o r a
p erso n ality trait, r a th e r t h a n a b ad e n v ir o n m e n t o r b a d tra in in g ,
cau sed th e p ro b lem . G lo b a l style refers to a c c e p tin g that th e p r o b ­
lem in volv ed m ost o f th e ir life situ a tio n s a n d w a sn 't sp ecific to o n e
Finding the Beliefs 73
/

situ a tio n , a n d sta b le refers to th in k in g th e p ro b le m w ould stay with

th e m for a lo n g tim e. A ny o f th ese th re e a sse ssm en ts are likely to
lead to d epression.
It is useful to d e te rm in e w h e th e r y o u r clients are view ing their
p ro b lem s th ro u g h o n e o r m o re o f th ese attitudes.

M eth od
1. Have y o u r clients m a k e a list o f th eir central problem s. Example: "I
h a v e tr o u b le in relationships."
2. Help th e m d ecid e h o w m a n y o f th ese p rob lem s are lo n g -term and
not likely to ch ange. Exam ple: "I will alw ays ruin relationships" ver­
sus "1 a m having tro u b le right now."
3. How m a n y gen eral p rob lem s rather th an specific on es? Exam ple: "I
will n ev er h av e a g o o d relationsh ip with a n y m a n " versus "I had
difficulty' relating to Fred."
4. Do y o u r clients b eliev e that they ca u se their ow n problem s, or do
t h e y th in k s o m e ou tsid e fo rce has created th e m ? Exam ple: "There is
s o m e th in g w'rong w ith m e for h av in g relationship problem s" ver­
sus "I h av e b ad luck in relationships."
5. Help y o u r clients to search for alternative explanations. If they have
ju d ged their p ro b lem to b e internal and p erm an en t, tran sp ose it to
ex tern al and tem porary. Do the s a m e if th e clients have ju d ged their
p ro b lem as outside them and transitory. Notice the difference it
m ak es in h ow th e client feels a n d w h ich em otio n s arise.

E x a m p le : The S tories o f D elm a a n d S u zan n e

To u n d erstan d h ow th ese ex p la n a to ry styles work, co n sid er the
cases o f D elm a and Suzanne. Both clients were divorced, and the cir­
c u m sta n ce s o f their divorces w ere very similar. Delm a felt as if she had
b e e n th ro u g h an earth q u ak e . T h e g ro u n d o f h er em o tio n a l support
w as totally shak en, sh e felt lost an d adrift, and sh e had con tem p lated
suicide. Su zann e, however, ex p erien ced only a sh ort period o f grief
a n d loss, qu ickly started datin g again, a n d felt m uch hap p ier th a n she
had w h en sh e was married. W hat was th e difference b etw een these
tw o w o m e n ?
T h ey h a d very different ex p la n a to ry styles. Delm a thought, "It w'as
m y fault w e got divorced" (internal blam e); "I will n ev er find an yon e
else" (stable); "N o b o d y will w an t m e now" (global); "I will live the rest
 T h f N f.w H and bo o k ..qe Cognitive T herapy T echniq ues
74

o f m y life a lo n e an d destitute" (p e rm a n en O .'S u z a n n e th o u g h t, "Free at

last. Free at last. T h a n k G od almighty, I'm free at last."
In ord er to co u n sel clients like D elm a it is n ecessa ry to invert their
ex p la n a to ry style. Therapists m ight c o n sid e r saying:

Your sp o u se had so m e th in g to do with y o u r div orce; it was

not cau sed b y so m e h y p o th etical flaw in y ou alone. M a y b e y o u r
chem istry to g e th e r wasn't su ita b le o r m a y b e h e w asn't m atu re
e n o u g h to b e m arried, o r m a y b e h e was e x trem e ly difficult to
live with. It ju st didn't su cceed with him (specific). Y our sad ness
will not last forever (u n stab le or tem porary).

W h e n D elm a's ex p la n a to ry style changed , h e r d epression w as sig­

nificantly reduced.

C om m en t
C ou n selin g ch ronically m e n ta lly ill clients o r g a m m a addicts that
th eir problem s are externally caused, narrow, a n d o n ly te m p o ra ry will
m ak e th em in calcu lab ly worse, b e c a u s e you will e n c o u ra g e th em to
deep en their denial. To b e helped, th ese p op u lation s need to accept
that th ey have a real p ro b lem that is inside o f th e m rath er th an in the
en v iro n m en t, and th at their p rob lem w on't sim p ly go aw ay in a c o u ­
ple o f weeks (see th e sections o n treating seriously m e n ta lly ill patients
and cognitive restructuring th erapy w ith addicted patien ts in ch a p ter
12 ).
This teaches an im p o rta n t lesson a b o u t all cogn itiv e tech n iqu es.
O u r cogn ition s are like paintings that o u r brains draw o f th e world.
T h ey are o u r in terpretations o f the realities w e face. But all im ages are
not o f eq u al v a lu e o r o f eq u al utility. Everyth ing is n o t totally s u b je c ­
tive. T h ere is a n outside world p rojectin g itself o n th e c a n v a s o f o u r
m in d s th at w e all m u st face. T h e clo ser o u r m en tal p ain ting's im ag e is
to the im ag e o n the outside, th e m o re ad ap tab le w e are a n d th e b e t­
ter w e can co p e w ith life. Early attem p ts to create th e s a m e cogn itiv e
self-affirm ations for all clients w e re sh o w n to b e v a c u o u s b e c a u s e the
reality th at each client faces is different. W h a t w orks fo r o n e client
doesn't necessarily w o rk for another. N othing rep laces k n o w in g the
person directly and w o rk in g individually with e a c h client.
So w h ich typ e o f ex p la n a to ry style is best: b e lie v in g that o u r p ro b ­
lem s are tem porary, specific, and extern al, like th e d epressed client
shou ld do, or b e lie v in g that o u r p ro b lem s are p e rm a n e n t, global, and
Finding the Beliefs
/

internal, like th e addict o r psychotic sh ou ld do? T he a n sw er is as ob v i­

ou s as it is ancient:
G od g ran t m e th e seren ity to accept the th in gs I ca n n o t change,
C h an ge th e things I can,
And th e w isd o m to know th e difference.

F u rther In fo r m a tio n
M a rtin S e lig m a n created the c o n ce p t o f ex p lan ato ry styles and has
ex p a n d ed it into a m a jo r th era p e u tic interven tion (see B u ch an an &
Seligm an , 1995; Petersen, Maier, & Seligm an, 1995; Seligm an, 1975,
1994, 1996; Seligm an & Jo h n so n , 1973). B ob b itt (1989) show s that
e x p la n a to r y style is a state rather th an trait-dep end ent.
 Groups of Beliefs

I n the early days of cogn itiv e therapy, w h e n it w as called cogn itiv e

b eh a v io ra l therapy, Bs were often con sid ered as individu al covert
stim uli p rod ucing e m o tio n a l and b e h a v io ra l responses. Taking the
lead from th e b eh av io ral roots o f the therapy, th eorists v iew ed c o g n i­
tion s as eith er con d ition ed stim uli paired with em o tio n a l resp onses
(as in the classical paradigm ) or as d iscrim in a tin g stim uli paired w ith
b e h a v io r and rein fo rce m en ts (as in o p e r a n t theory').
Nowadays o n e doesn't h e a r m u c h o f this theory; co g n itio n s are
m ore likely to b e view ed in groups, gestalt patterns, schem as, and
w ays o f organizin g th ou g h ts th an as in dividu al triggers. At th e heart
o f m o d ern cognitive therapy is th e collective a rra n g e m e n t o f clients'
c ogn ition s rath er th a n th e qu an titativ e a sse m b ly o f d isco n n e c te d data.
T he em p h a sis n ow is on h o w clients creatively tran sform data, h ow
th ey g a th e r raw bits o f perceptual and m e m o r ic in fo rm a tio n and
sculpt th em in to intricate patterns, them es, and stories, a n d h ow
clients create th eir ow n co n ce p tu al world.
T here are m a n y m e th o d s o f discovering clients' co g n itiv e patterns,
b u t this ch a p ter discusses th o se th at w'e h av e fo u n d to b e m o st use­
ful.

C o r e B e l ie fs

Principle

At th e b a se o f m o st em o tio n a l p ro b lem s is often o n e co re belief. It

is the k ey ston e B th at h oick u p th e o th e r beliefs. These c o r e attitudes
Groups of Beliefs

m ay a n c h o r m a n y o f th e client's psychological problem s. O nly a few

key attitudes can c a u s e all o f th e dam age.
Therapists h av e k n o w n for so m e tim e that client's beliefs are m ul­
tilayered. Clients h av e surface beliefs and u n d erly in g ones. T h ese cog­
n ition s are psych ologically related. Therapists ca n explain these layers
to th eir clients b y draw ing the inverse pyram id pictured in Figure 3.1.
At the top o f th e pyram id are surface thoughts, th e beliefs that
clients are aw are o f a n d that th ey usually reveal to others. W h en
clients are asked w h at th e y are thinking, th ey u su ally pick out o n e o f
th ese su rfa ce beliefs. At th e b o tto m o f th e pyram id are clients' core
a ssu m p tio n s o r co re beliefs. These are not readily apparent to clients
o r to others, and th erap e u tic w ork is required to u n cov er them. It's not
n ecessarily true that th ese beliefs are u n co n scio u s or that clients fear
u n co v erin g them (this is p ro b a b ly true o f o n ly a small p ercentage o f
clients' beliefs, alth ou g h therapists from a p sy ch o d y n a m ic orientation
w ould disagree). But core beliefs are so basic, so fu ndam ental, that
clients m ay not b e aw are that th ey h av e them. It is a n alog ou s to a fish
n o t b e in g aw are o f w ater b e c a u s e it has lived in w ater all its life and
has n e v e r b e e n o u t o f it. It doesn't kn ow th at w ater exists. Likewise
clients w h o have always lived w ith a co re b e lie f m ay n ot b e aw are o f
its existence.
 Th e N e w .H andbook , of .Co g nitive T herapy T echniq ues

M eth o d
Finding y o u r client's co re beliefs is im p o rta n t for all later work.
C ognitive therapy is effective o n ly if th e therapist is w o rk in g o n the
correct co re beliefs.
1. Relax y o u r clients for five m inutes. G ive th e m a tra n sitio n from
th eir co n ce n tra tio n o n ex tern al ev ents an d c h a n g e th eir focu s to
internal events.
2. Turn th e clients' focu s tow ard th e A. H ave th em im a g in e as clearly
as th e y can th e situation th at th e y are c o n ce rn e d ab ou t. H ave them
use all o f th eir senses (vision, hearing, smell, taste, kinesthetic) to
m ak e th e A as vivid as th ey can.
3. W h ile y o u r clients h av e the A clearly in mind, focu s o n th eir Ce,
th eir em otion s. W h at e m o tio n em erg es w h ile im ag in g th e A? Ask
th em n o t to m a k e up a n em o tio n ; let it c o m e in w h a te v e r w ay it
com es. Let th em feel it.
4. Now ask th e clients to focus o n their thoughts. Ask them , "W h a t are
you telling y o u rse lf right now a b o u t th e A that m ak es y o u feel the
em o tio n at C? Let th e first th o u g h ts th a t p op in to y o u r m in d
emerge.'' If y o u n ee d to, take a q u ic k b r e a k and w rite th e b e lie f
down, th en return to y o u r clients' m e n ta l focusing. (At this p oint
you accept clients' surface beliefs.)
5. Keep their b e lie f clearly in m ind a n d ask clients the qu estions, "So
w h at i f . . . ?" or "W h y d o e s it m atter t h a t . . . ? ' ' Keep ask ing th e sa m e
q u estio n s until you find th eir core answer. It's im p o rta n t to listen to
clients' answ ers a n d to w ait for th eir im a g in a tio n to o rig in a te a
thou gh t. (You m a y find it useful to write th e w h o le process dow n
in ord er to help you keep track o f y o u r client's answers.)

E x a m p le
A b u s in e s s m a n client o f ou rs w as w o rried a b o u t g iv in g talks to
large professional audiences. W e follow ed th e se steps to help h im find
his co re B.

1. W e asked th e client to sit back, relax, and t u r n his a tten tio n inward.
2. The client pictured h im self sta n d in g at th e p o d iu m in a lectu re hall
with m a n y professional p e o p le staring at him . He heard th e m u r­
m urs o f th eir con versation s, sm elled th e coffee b rew in g, noticed
how it felt to rest his arm s o n th e p o d iu m a n d to h e a r th e crackle
in th e so u n d system. ,
Groups o f Beliefs
79
/

5. I le tu rn e d his focus inside and n oticed th e ten sio n a n d tightness in

his chest. He felt scared.
4. W h e n h e c h an g ed his focu s to his thou gh ts, the first o n e that
p o p p e d in to his h ead was, "They m a y not like m y speech."
5. W e th e n en g a g e d in th e follow ing dialogue:

Q U EST IO N : So w hat if th ey don 't like y o u r speech?

A N SW ER: Then they w o n 't respect me.
Q U ESTIO N : W h a t d o e s it m a tter if th e y don 't respect you?
A N SW ER: If th e y d o n 't respect me, I will feel bad.
Q U EST IO N : W h y will y o u feel bad?
A N SW ER: If I d o n ’t h av e e v ery b o d y like me, I feel bad.
Q U E ST IO N : W h y d o you n ee d e v ery b o d y to like you ?
A N SW E R: Because I don't like myself, and I n eed to prop m y se lf up
w ith others' positive im p ression o f me.

"I don 't like myself," was the c o r e belief. To elim in ate his fear o f
p u b lic speaking, w e addressed this belief.

C om m en t
Clients u su a lly h av e a series o f core beliefs co n n ec ted to a series o f
inverted pyramids. In a n y particular A -C situation, several pyramids
m a y b e activated, c a u s in g different e m o tio n a l an d b eh a v io ra l
responses.
W h e n trying to c h a n g e beliefs, it is u su ally b e st not to work o n the
c o re b e lie f first. It is to o far away from the client's im m ed ia te aw are­
ness, and often n ot acknow ledged. It is also m ore co n n ected to an
integrated netw ork o f o th e r co re beliefs; this m akes it far m o re diffi­
cult to extract from th e entan g led w eb o f beliefs. Cognitive therapists
u su ally w ork from th e surface o f th e pyram id dow nw ard, o n ly tack­
ling c o r e beliefs after th e client has show n so m e skill with th e surface
thoughts.

Further In fo r m a tio n
T h e te c h n iq u e d escribed has b e e n called the dow nw ard arrow tech ­
nique. (The origin o f this label m ay h a v e c o m e from o n e o f m y earlier
works— M e M u llin & Giles, 1981, pp. 4 2 - 4 8 — in w h ich w e used d ow n ­
ward arrow s to illustrate th e process.)
G u id iano and Liotti have d o n e so m e o f the b est theoretical w ork on
 T h f N fw HANDBOOK OF COGNIIlV f JE EER A EI IECHMIQ-U-ES

core beliefs. T hey call th em th e "m etap h y sical h a r d -c o r e " a n d explain

them as th e deep, relatively indisputable, tacit s e lf-k n o w le d g e that
p e o p le develop du ring their lives (G uidano & Liotti, 1983, p. 66). They
are m etap h ysical b e c a u s e th ey are n ot based on ex p erien ce, logic, or
reasoning; th ey are c o r e u n p ro v e n assu m p tio n s (also see G uidano,
1987, 1991).
Judith Beck uses a c o r e -b e lie f w o rk sh e et to m o n ito r th e progress o f
ch an gin g negative co re beliefs (J. Beck, 1995, 1998).
Core beliefs are a m a jo r c o m p o n e n t o f A aron Beck's th e o r y an d are
related to w h a t h e calls "p rotosch em as" (Beck, 1996, pp. 11-5).

L ife Th em e s

Principles

W h e r e d o clients' co re beliefs c o m e from ?

According to m ost clients, th ey c o m e from th e big, im p o rta n t
things, th o se major, life-sh atterin g ev en ts th at h a p p e n to all o f us.
W h e th e r it b e the death o f a parent, th e tim e th ey w e re in ju red a n d
w ent to th e hospital, or the day th e ir b ro th e r o r sister was b o r n — th e
ev en t seem s crucial in th e form ation o f th eir personalities.
A lthou gh th ese ev en ts are im portant, w e found that it is n o t th e big
swirling things th at create clients' c o r e beliefs, it's th e little insignifi­
can t things. Clients can trace m a n y o f th e ir p ro b lem s b a c k to w h a t
seem s like a trivial event. M a y b e it's th e tim e th ey did n't receive the
special gift th at they w an ted fo r Christm as, or w h e n th e y cou ld n 't find
their m o th e r in th e su p erm arket, o r th e night th e y forgot th e ir lines in
th e Easter play, or th e tim e th ey w'ent to th e party and n o b o d y asked
th em to dance.
Trivial ex p erien ces c a n pack so m u c h pu n ch that th ey h a u n t clients
for years. S o m e theorists h av e suggested th a t th e se little ev en ts im pale
p eople b e c a u s e they sy m b o lica lly rep resent so m e deep, u n d erly in g
h u m a n conflict. For instance, a client m a y r e m e m b e r step p in g in d u ck
drop pings b ec a u se h e asso ciates it w ith in c estu a l desires d u rin g potty
training. But a sim p ler ex p la n a tio n m a y b e called for.
Events are not critical b e c a u s e o f w h a t h a p p e n e d to clien ts b u t
rath er b e c a u s e o f w h at th e y concluded a b o u t w h a t h a p p e n e d . T h ey
m ay reco v er from a tra u m a tic ev en t like th e d e a th o f th e ir g r a n d ­
m o th e r if th ey c o n c lu d e th a t G ra n d m a h a d a full, rich life a n d is liv­
ing with G od in heaven. But th ey m a y n e v e r get o v e r th e d e a th o f
th eir pet goldfish if th ey c o n c lu d e th a t G od sh o u ld n 't let g old fish die
Groups of Beliefs_ _ _ _ _ _ _
/

sin c e He didn't c re a te a goldfish h e a v e n for th e m to g o to.

It's n o t th e streng th o f the e x p e rie n ce that m akes the ev en t critical;
it's th e b ru te force o f th e client's conclu sion . Clients' ded u ctions ab o u t
tiny things can b e en o rm o u s. It's as if th ey are w alking d o w n o n e path
in life w h e n th ey trip o v e r a p e b b le and su dd enly turn dow n a totally
different road. T h ese co n clu sio n s b e c o m e life th em es that serve as
road m aps g u id in g th em throu g h life.

M eth o d
Becau se o f th e im p o rta n ce o f th ese events and the life th e m e s that
form fro m th em , cogn itiv e therapists sh o u ld m a k e a list o f the most
significan t ex p erien ces in a client's life— n o t significant from th e out­
sider's p oint o f v iew b u t from th e client's. T he therapist shou ld collect
th re e lists: 10 critical incidents from ch ildhood , 10 from adolescence,
a n d 10 from a d u lth o o d . Discuss each ev en t in great detail, paying
clo se a tten tio n to w h a t th e client conclu d ed happened. T he client's
attrib u tions are th e key— so m e clients h a v e held to erro n eo u s co n clu ­
sion s years after th e ev en t occurred.

List o f Critical Events a n d Life T h em es

1. C onstru ct a list o f th e 50 m ost critical ev en ts that have hap p en ed in
y o u r client's life. D o n ’t only c h o o s e negative events (like the death
o f a loved one); pick th e tu rn in g points in th eir lives th at could be
positive o r negative (like ea rn in g a degree or getting married), or
p ick ev en ts th at m ay n ot seem significant to th e outside observer. If
th ey are im p o rtan t to the client, include them . You need th ree lists:
10 in cidents from th e client's ch ild h ood , 10 from adolescence, and
10 fro m adult years.
2. C om p ile th e inciden ts in term s o f As and Ces. W h at h ap p en ed and
how did th e clien t feel?
5. O n c e y ou h a v e collected their thirty A -C incidents, try to find the
core Bs for each one. W h a t did they tell them selves at that time that
g o t th em so upset? It's n o t w h a t they th in k o f it now, it's w h at they
th o u g h t a b o u t it then. W h a t did they co n clu d e ab out th em selves or
a b o u t o th ers o r a b o u t th e world b ec a u se o f this event? In finding
th e ir Bs, r e m e m b e r to lo o k for th e different types o f beliefs m e n ­
tioned in the previou s ch ap ter: expectations, attributions, labels,
self-instru ctions, etc.
4. G o b a c k th ro u g h th e client lists starting with ch ild h o o d and w ork­
ing th ro u g h to adult, a n d lo o k for the recu rren ce o f th e sa m e th em e
 T h e N e w -Handbo o k of Cognitive T herapy T echniq ues

o r Bs. T he w ords for the th e m e m a y h av e c h a n g ed o v er th e years.

As a child th ey m a y have con clu d ed , "I'm n o g o o d b e c a u s e I can 't
play baseball." As an adolescen t, "I'm n o g o o d b e c a u s e I don 't have
a pretty girlfriend." As an adult, "I'm n o g o o d b e c a u s e m y c o m p a n y
w on't p ro m o te m e to a lead ership position." T h e w o rd s are different
b u t the life th e m e is the sam e— "I am inferior as a male." M a k e a list
o f th ese beliefs.

M aster List o f B eliefs

As the final exercise in g a th e rin g y o u r client's beliefs, d ev elo p a
m aster list o f beliefs. This list sh ou ld includ e th e m a jo r Bs y o u h av e
gath ered from all o f y o u r o th e r exercises. T h ere shou ld b e at least 30
or m o re item s on th e list and it sh o u ld b e as c o m p r e h e n s iv e as you
can m a k e it.
N u m b e r each th o u g h t and write it o u t separately. D on't worry'
a b o u t the w ord in g for now ; y o u c a n correct it later. T h e o n ly m istak e
you can m a k e is n o t to in clud e all o f y o u r client's Bs. You c a n n o t h a v e
to o m a n y on th e list— if you du p licate s o m e th ou g h ts y o u can cull
th em out later.
M ost o f the cou n selin g te c h n iq u e s w e use in cogn itiv e restru ctu r­
ing th erap y are b a sed on this m a ster list.

E x a m p le 1
O v e r th e years, m a n y faulty life th e m e s h a v e b e e n g a th e re d from
clients. Here are s o m e exam ples.
Albert was a C stu dent in grad e school. This average p erfo rm a n ce
was hard on him b eca u se his old er b ro th er a n d sisters had b e e n the
top students in their classes. O n e term he had tried as hard as h e could
in his m a th class. He previously had n ev er received m o re th a n a C
minus, b u t this time, through hard work, h e was a b le to get a B+. W h e n
he received his report card, h e ran h o m e to sh ow his dad. After g la n c­
ing at it, his dad said, "That's okay, son. Now, if you ju st put in a little
m ore effort, you can earn an A next time." T h at was it; it was all his dad
had said. From this "little" event, Albert form ed so m e b ig conclusions.

• "If y ou don 't do things perfectly, y o u m ig h t as well n o t d o th em at

all."
• "To b e w orthw hile, y ou h av e to b e th e best."
• "I can n ev er b e th e b e st in everything, so I can n e v e r b e w o rth ­
while." *
Groups .of Beliefs 83
/

E x a m p le 2
C onsid er a client I'll call "Marina." Sh e entered th erapy b ec a u se she
w as afraid to b e alone. S h e fell terrified w h e n e v e r sh e was by herself.
As a result sh e collected friends and tried to get e n o u g h o f th em so
th a t sh e h ad an a m p le supply. Sh e stockpiled boyfrien ds also, and was
afraid to end a n y relationsh ip in case sh e ran short. At parties she
w o u ld h av e all o f h e r boyfrien d s lined up on th e couches, sitting and
staring at each other. It m ad e h er feel secure, b u t it put a strain on the
festivities.
M a rin a m a d e a list o f h e r critical events. Sh e could find no instances
w h ere a parent o r s o m e o n e else had a b a n d o n e d or left h e r as w e
m ight suspect. Sh e did find a few m in o r exp eriences th at m ost chil­
dren h a v e had: sh e h a d chick en p ox at the age o f 6 and rem em b ered
her m o th e r sitting up all night for several nights; sh e lived o n a busy
street an d her fath er had w arned h e r repeatedly that she shou ld never
cross th e street b y herself, and sh e was told n ev er to g o to parties by
h erself b e c a u s e h e r tw o o ld er sisters had gotten p regnant before
they'd g o tten married.
The co n clu sio n s and life th em es sh e form ed from these incidents
w ere not minor. From a w h ole series o f petty incidents, sh e developed
th e follow ing life p h ilosophy:

• "The world is a big and d an g erou s place, and I a m w eak and h elp ­
less."
• "I need o th e r p eople a ro u n d m e to b e safe."

W ith this p h ilo so p h y s h e had n e v e r allow ed h erself to b e alone,

and h a d su rrou n d ed h erself with as m a n y people as sh e could for
safety.
T h ese tw o ex a m p le s sh ow th at m a n y em o tio n a l problem s have the
sa m e so u rc e — little events w ith b ig conclu sions. These conclusions
start ad d in g up in clients' lives and form th eir life th em es. O ver time
th ese life th e m e s b e c o m e th e road m aps that clients use to navigate
th eir life exp eriences. If their th em es are distorted th ey get o ff course
a n d en d u p in the w ro n g place.

C om m en t
O n e o f th e m ost useful and im p o rta n t tech n iq u es in cognitive th er­
ap y is g a th e rin g y o u r clients' life th em es. Take as m u ch tim e as is
n ee d e d to develop a c o m p reh en siv e list. This process is very revealing
84 T h e N e w H andbo o k qe Co g nitive T herapy T echniq ues

to y o u r clients; they start to see h ow th ey h av e m isin terp reted m a n y

situations b a sed o n the s a m e an cient cogn itiv e m istake. M o st o f th e
rem a in in g clinical tim e is usually sp en t w o rk in g o n c h a n g in g th ese life
th em e s rather th a n w o rk in g o n idiosyncratic beliefs th at o n ly o c c u r in
limited situations.

F u rth er In fo r m a tio n
Life them es h av e b e e n an im p o rta n t c o n ce p t in psycholog}' fo r so m e
time. Csikszentmihalyi and Beattie (1979) review so m e o f th e earlier
theorists such as Berne (1961, 1964), Erickson (1982), and Erickson and
Rossi (1981). Later w o rk can b e found in G u id ano (1991) and Freem an
(1993, 1994), and Freeman, Sim on, Beutler, and Arkowitz (1989) w ho
reveal that life them es and personal sch em as m a y b e form ed b y h ow
p eople resolve th e various life crises th ey m u st face.
O n e o f the m a jo r develo p ers o f th e principles o f life th e m e s is Jef­
frey Young. He calls th em sch em as rath er th an life th e m e s and has
created a th erapy with sc h em a s as th e p rim ary focu s— s c h e m a -
focused therapy. His a p p roach goes into m o re detail a b o u t sch em a
d o m ain s and d e v elo p m en tal origins. It is b e st to read h im directly
(Bricker, Young, & Flanagan, 1993; M c G in n & Young, 1996; Young,
1992, 1994; Young, Beck, & W einberger, 1993; Y oung & Rygh, 1994).

C o g n it iv e M a ps

Principles

C ognitions are like pieces in a jigsaw puzzle. T h e individual pieces,

th ou gh essential, don 't reveal the c o m p le te picture. W e se e o u r clients'
c om p osition s on ly w h e n w e put all o f th e pieces together. O u r clients
respond to th e story an d overall th e m e rath er th a n to th e su b p arts
th at m a k e up these stories.

Method
1. A ssem b le a cogn itiv e m ap from y o u r client's m aster list o f beliefs.
You c a n d o this b y taking each th o u g h t o n th e m aster list and c o m ­
paring it to every o th e r thought. Ask y o u rse lf and y o u r client, "How
are the th ou g h ts alike? How are they different? W h ic h th o u g h t
com es first a n d w h ich follows?" For exam p le, if a client's list
includes the thoughts, "I a m an evil person," a n d "I n ee d to b e p e r­
fect," d e term in e how th ese tw o th ou g h ts are related. Trying to b e
Groups of Beliefs 85
/

perfect m ay b e an attem pt to m ak e up for feeling evil. Feeling evil

m a y result from failing to live up to perfectionist standards.
2. Record th e relationsh ips a m o n g the th ou g h ts o n a graph or co g n i­
tive m ap (see figures 3.3 and 3.4).
3. In a session g o o v e r the m ap w ith y o u r client and m a k e any
ch a n g es suggested. You m ay explain th e principles by using the
draw in g and ex p la n a tio n in figure 3.2.
This draw ing illustrates h ow a cognitive m ap works. Each dot
rep resents a n individual th o u g h t a n d the 8 dots can b e co m b in ed
to form a su rface pattern. However, o n closer inspection there is
also an u n d erly in g pattern that can b e seen— a cube. A cognitive
m a p is n o t the individual dots or surface pattern, b u t th e underly­
ing c u b e they form . O n c e seen, w e react m ore to the c u b e than the
dots. In th e sa m e way, w e pay m ore atten tion to th e total pattern o f
beliefs th an to any individual one.

E x a m p le
P eople w ith different em o tio n a l p rob lem s have different cognitive
maps. O n th e basis o f extensiv e e x p e rie n ce with a variety o f clients'
p rob lem s, cogn itiv e restructuring therapists have identified the m ap in
figure 3.3.
This kind o f cogn itiv e m ap clearly d em on strates w h y a client would
h av e p an ic attacks. M a n y clients grew up b e in g overprotected. They
learn ed to th in k that th e world was a d ang erou s place and th a t they

F IG U R E 3.2 N e c k e r 's C u b e ( B r a d l e y & P e t r y , 1 9 7 7 )

86 Till; New H a n d b o o k ,o f C o g n i t i v e T h e r a p y T e c h n i q u e s

The w orld is a big and 1 am w e a k and helpless.

hostile place.

I need to control everything

1 need to control the outside 1 need to control the inside

(my environment). (m y emotions).

A n y situation I can't control

is dangerous.

Novel situations are Places 1 can't escape from A n y strong em otion is

dangerous. are dangerous. dangerous.

F I G U R E 3.3 C o g n itiv e m a p fo r clien ts w ith p a n ic rea ctio n s

were too w eak an d helpless to ta k e ca re o f them selves. To co m p e n sa te,

th ey tried to co n tro l ev eryth in g— the ou tsid e e n v ir o n m e n t a n d th eir
inside feelings— o n ly th e n did th ey th in k th ey could b e safe. It didn't
work; th ey were u n ab le to co n tro l e v e ry th in g so th e y started to have
p an ic attacks. W h e n e v e r they w ere faced w ith a situ a tio n in w h ich
they w eren't in full control, w h e th e r th ey w ere p assengers in s o m e o n e
else's car or sat in the front row at church, o r felt a n y stro n g e m o tio n
such as pleasure, anger, or sad ness th ey w o u ld panic. T h e m o r e they
tried to control th eir fears, the m o re th ey feared. T h eir cogn itiv e m aps
caused a vicious circle.
O th er clients with o th e r p rob lem s h av e different co g n itiv e maps.
Clients w h o are ch em ically d e p en d en t o ften sh ow th e p a ttern in fig­
ure 3.4.
At th e heart o f their cogn itive maps, addicts d en y th e ex iste n c e o f a
ch em ical problem . E xten d in g ou tw ard from this b a se th ey p arad oxi­
cally b eliev e that they can c o n tro l th eir use ("I can sto p after a co u p le
Groups of Beliefs 81

M y em otional problems I am not responsible for

cause me to use. taking drugs.

It's not that serious.

F i g u r e 3.4 C o g n i t i v e m a p f o r c h e m i c a l l y d e p e n d e n t c lie n ts

o f beers") w h ile th in k in g th at they aren't responsible ("My bad child­

h o o d causes m e to snort cocaine").

C om m en t
T here are m a n y o th e r types o f cognitive maps. Each o f the h u n ­
dreds o f psychological p rob lem s has its ow n map, and every person
has his o r h e r ow n variations. It is essential for th e therapist to accu­
rately m ap th e key c o m p o n e n ts o f each client's cognitions.

F u rther In fo r m a tio n
T h e c o g n itiv e -m a p c o n ce p t c o m es from o n e o f m y earlier b o o k s
(Me M u llin & Giles, 1981, ch ap ter 7). A lthou gh th ey d o not use the
term, m a n y cogn itiv e therapists discuss the pattern o f cognition s c o n ­
nected to various clinical p ro b lem s (Beck, Emery, & G reenberg, 1985;
Beck, Freem an, & Associates, 1990; D o b so n & Kendall, 1993; Ellis, 1996;
Foy, 1992; Freem an & Reinecke, 1993). Y oung integrates clients'
sc h em a s in to a m ap u sing the S ch e m a C onceptu alization Form (Young,
1992). Dattilio (1998) an d Freem an an d Dattilio (1992) discuss the SAEB
system , w h ich provides a stru ctu red ou tlin e o f cogn ition s a n d e m o ­
tion s c o n n e c te d to p a n ic attacks.
Countering Techniques: Hard

j\. all cogn itive restru ctu ring te c h n iq u e s that

SIN G LE THEORY u n d e r l i e s
em p loy countering. T he th e o ry is this— when fl client argues against an irra­
tional thought and does so repeatedly, the irrational thought becomes progressively
weaker. ,
This th e o r y does n ot assu m e that c o u n te rin g o n e th o u g h t w ith
a n o th e r can m agically c h a n g e an e m o tio n a l-p h y s io lo g ic a l state.
Rather, it presum es that th e c o u n te rth o u g h t m ig h t elicit affective c o n ­
ditions, w h ich in turn red uce negative e m o tio n s or rem o v e th e stim -
ulus triggering em otions.
The roots o f co u n te rin g are fou n d in th e rea lm o f p h ilo s o p h y rather
th a n psychology. Disputing, challenging, an d argu in g are all a n c ie n t
m etho d s, old er th an Plato's dialogues. These te c h n iq u e s are u sed b y
virtu ally ev ery o n e in all kinds o f situations— fro m b a r r o o m a rg u m e n ts
a b o u t religion to presidential debates.
This section o n cou n terin g is subdivided into th ree chapters, each
describing a different typ e o f countering. C hapters 4 and 5, o n hard
cou n terin g and soft countering, describe tech n iqu es th a t pair e m o ­
tional states with cogn ition s to p rod uce attitude change. Hard c o u n ­
tering deals w ith assertive em o tio n s; soft co u n te rin g deals with
relaxing ones. C hapter 6, o n o b je ctiv e countering, describes te c h n iq u e s
that attem pt to d isco n n e ct e m o tio n a l states from b e lie f m odification.

P rin ciples
Hard co u n te rs are cognations th at go against irrational th o u g h ts. A
hard c o u n te r can b e o n e w ord ("Nonsense!"), a p h ra se ( Not true! ), a
Countering Techniques: Hard 89
/

s e n te n c e ("N ob od y at this party cares if I'm not g o o d at charades"), or

an eleg a n t p h ilo so p h y ("My p u rp o se in life is not to b e as p op u lar as
I can, b u t to develop m y ow n potential, ev en if others disapprove").
T h e ideal hard c o u n te r is a p h ilosop h y th a t pulls in a hierarch y o f
values, perceptions, an d exp erien ces, drow n in g th e dam agin g th ou ght
in pow erful cu rren ts flow ing in th e op p o site direction. Sh ort phrases
o r slog an s can b e useful w h e n they are tied to a co u n terp h ilo so p h y —
not b e c a u s e th e y h a v e the strength to o v e rco m e th e irrationality, but
b e c a u s e th ey are q u ick rem inders o f the p h ilosop h y itself. T he thera­
pist sh ou ld h elp th e client fo rm co u n te rs th at are grou n d ed in such a
philosophy.

M eth od
1. Help clients identify hard cou n ters for each irrational thought.
M a k e sure th ey o p p o se th e irrational th ou g h t forcefully. For e x a m ­
ple, "It is im p o ssib le to su cceed in everything y ou do" is a b etter
c o u n te r th a n "It is often qu ite difficult to succeed in everything you
do."
2. Have clients d ev elo p as m a n y cou nters as possible; 20 cou n ters are
tw ice as g o o d as 10.
3. M a k e sure the co u n te rs are realistic and logical. Cognitive restruc­
turing th era p y does not su b scrib e to the pow er o f positive th in k ­
ing, in w h ich p eople often tell them selves positive lies. Instead, w e
stress th e pow er o f truthful, realistic thinking, asking clients to say
tru e things to them selves, not ju st things that sound nice. For e x a m ­
ple, a lth o u g h it m ay feel g o o d to think that "life gets b e lte r with
each p assin g day," it's n ot true; so m e days things get worse.
4. Instru ct clients to dispute irrational th ou g h ts repeatedly. M on th s
m ay b e need ed for this te c h n iq u e to b e effective, and m a n y clients
b a lk at this investm en t o f time, saying t h e / v e already tried the
te c h n iq u e to no avail. After exp lorin g w hat the clients' previous
efforts were, th e therapist usu ally discovers that they h av e argued
with them selv es for an h o u r or two. W h a t clients m u st understand
is that th ey m ay need to argu e against a b e lie f as m a n y tim es as
they have previously argued in its favor. It m ay take an h o u r a day
fo r a y e a r or m o re to o v e rco m e a lifelong core belief.
5. Ensure th a t each c o u n te r is in th e sa m e m o d e as the irrational
th o u g h t. Pair visual irrationalities with countervisu alizations, lin­
guistic errors with linguistic counters, angry beliefs with c o m p a s­
sio n a te ones, passive th ou ghts with assertive ones, proprioceptive
 T h e N e w H a n d b o o k o f C ognitive T h e r a p y T e c h n i q u e s

irrationalities with prop rio cep tive realities, etc. For ex am p le , a client
w h o fears tall b uild ings b e c a u s e s h e pictures th em falling o v e r will
b e b etter helped b y a c o u n terv isu aliza tio n o f a b u ild in g c o n ­
structed o n th e rock o f G ibraltar th an b y a linguistic a rg u m e n t that
build ings don 't fall over. W h e n th e c o u n te r is o f th e sa m e m od ality
and logical typ e as th e irrational thou gh t, it is m o re likely to h av e
a disruptive impact.
6 . Attack all o f th e clients' irrational beliefs, n o t ju st s o m e o f th em . It's
im p o rta n t to tie th e co u n te rs to all o f th e co g n itio n s th at p ro d u ce
e m o tio n a l responses. As sh o w n in th e chapters o n find ing beliefs, if
m a jo r beliefs h av e b e e n missed, th e th erap ist m ay b e u nsuccessful
in red ucing em otions.

E x a m p le
At o n e p oint in m y career, I w orked in a sm all to w n w h e re few
o th e r psychologists practiced, and I often received calls from th e edi­
tor o f th e local new sp ap er in q u irin g a b o u t variou s psychological
issues. O n e particular call stands out. T he ed itor n eed ed a q u o te for an
article a b o u t ca b in fever. Before h e h u n g up h e ask ed if I could offer
o n e suggestion h e could give his readers so th at th ey m ig h t avoid psy­
ch ological problem s. I an sw ered that th e re w'ere m a n y su ggestions;
picking ju st o n e w ould b e difficult. But h e p u rsu ed his request, asking
for o n e central cause, o n e c o m m o n th e m e u n d erly in g m o st e m o tio n a l
problem s, ju st one! I said I w ould th in k a b o u t it and get b a c k to him.
S o m e tim e later I p h on ed b a ck with th e m ost central cau se I could
th in k of. I said, "M ost p e o p le w h o h av e psychological p ro b lem s have
th em b ec a u se they don 't run to the roar"
At first he didn't u n d erstan d and m a y h av e th o u g h t th ere was
so m eth in g w ron g w ith me. Then I told h im a story' 1 h ad read m a n y
years before:

The d a u g h te r o f a m issionary lived o n th e Serengeti plains in

Africa. Sh e had grow n up a ro u n d lion prides an d noticed that,
with regard to th eir old er m em b ers, th ey acted differently from
o th e r species. W h ile o th e r a n im a ls left th eir elders to die w h en
they could no longer catch their ow n gam e, th e lion prides did­
n't; they used th em to assist in the hunt. T h e pride w o u ld trap
a n te lo p e and o th e r an im als in a ravine, a sse m b lin g y o u n g lions
o n o n e side an d th e old, clawless, to o th less lions o n th e other.
Countering Techniques: Hard 91
/

T h e old lions w o u ld then roar as loudly as th ey could. T he a n i­

m als in th e ravine would h ear th e roar and ru n in th e opp osite
direction, straight into th e waiting g ro u p o f yo u n g lions, (them e
c o m e s fro m Bakker, 1982)

The lesson for the a n te lo p e was clear, th o u g h few were left to b e n ­

efit from it. Had th ey run to the roar, they w ould have b e e n safe; but
they were to o afraid o f th e noise. By ru n ning away from the sou n d o f
danger, th ey ran into th e d an g er itself.
The story m ay not b e true, b u t it is helpful noneth eless b ec a u se it
sy m b o liz es a serious p rob lem that m ost clients have. T hey turn away
from w h a te v er it is that th e y h av e a difficult time facing— th ey run
aw ay from th e roar.
A n x iou s clients ru n from fear, trying to find a calm , safe place to
h id e o n th e planet. If th ey are afraid o f flying, they avoid planes. If
th ey fear crowds, th ey stay h o m e b y them selves. If they are scared o f
water, th ey avoid sw im m in g in lakes and oceans. T h eir fears never
d im in ish ; th e y o n ly increase. T he m o r e they run, the m ore afraid they
b eco m e.
Depressed clients run from th e b e lie f that th ey are th e sa m e as
e v e ry o n e else. It m ay sou n d strange that m a n y depressed people are
arrogan t; it w ould seem to b e th e opposite. But m a n y therapists have
found th at b e n e a th the depression, their clients h a r b o r th e curious
e x p e cta tio n th a t th ey are su pposed to b e perfect, and their depression
arises w h e n th ey find o u t th a t th e y aren't. So th ey ru n from the real­
ity that th ey aren't d em igod s b u t instead fallible h u m a n beings like
e v e ry o n e else.
A lcoholics and drug addicts run away at a feverish pace, refusing to
accept th a t th ey are addicted. T h ey fight th e truth and h o p e to get
aw ay with it. T h ey see o th e r p eople drin k in m od eration and th in k
th ey can d o th e sam e ; th ey refuse to accept that they are b io ch em i­
cally different from others. A lcoholics and o th e r addicts can lose
ev eryth in g— t h e ir families, jobs, and h ea lth — b u t they keep pretend­
ing th ey can use drugs o r alcohol safely.
T h e so lu tio n to these p ro b lem s is the m oral o f the lion story that I
tell all m y clients. Stop running aw ay! If clients faced their problem s, they
could solv e m ost o f them . Had the w a te r -p h o b ic client approached
water, put his feet in th e surf, paddled arou n d in the shallow end o f
sw im m in g pools, and forced h im s e lf to sit in row b oats, his phobia
w ould h av e b e e n c o n q u e re d years ago. Had th e depressed w o m a n
92 IH E N .E W _H A N M Q Q li)F COGNITIVE THF-RAPY TECHNIQUES

categorically accepted h e r s e lf as a fallible h u m a n b ein g , sh e w ould not

have b e c o m e depressed w h en sh e m a d e m istakes. And had th e c h e m ­
ically d e p en d en t client c o m p le te ly accepted th at h e w as in ex tricab ly
hooked, h e could h av e finally figured o u t that h e m u st stop.
W h at is the lesson for all clients? Run to the roar!
W h a t follows are variou s m e th o d s o f tea ch in g y o u r clients to face and
attack th eir beliefs.

C o u n t er a t t a c k in g

Principles

Hard c o u n te rin g is an em o tio n a l process as well as a n intellectual

one. Therapists can pair e m o tio n s with beliefs, a n d th ey can use their
clients' strong em o tio n s to c h a n g e beliefs directly.
1 use an an alog y to explain to clients h ow stro n g e m o tio n s c a n help
them c h a n g e their dam agin g beliefs. I call it th e "M elted W a x Theory."

Consider, fo r a m om en t, th at th ou g h ts are like w a x im p res­

sions in y o u r brain. T hey are often form ed w h e n w e h a v e a
strong em o tio n like fear o r anger. These e m o tio n s a ct o n y o u r
thou ghts like heat, cau sin g th em to liquefy a n d reform in to new
beliefs.
W h e n th e h ea t o f high e m o tio n a l arou sal has dissipated, the
th o u g h t is solidified. To c h a n g e th e b e lie f y o u h av e to eith e r chip
aw ay at th e w a x im pression, w h ich takes a lo n g tim e, or reheat
th e w ax so th e th o u g h t can b e rem olded. If you get angry' and
assertive e n o u g h w ith irrational thoughts, it is like h ea tin g them
up so th at they can b e poured into a new mold.

T he intensity o f em o tio n th e client invests in a c o u n te ra tta c k is the

key to its success. Disputing is m ost effective w h e n th e client attacks a
th ou gh t with em o tio n in a high state o f arousal. T h e ex p ressio n o f
em o tio n virtually elim inates th e repetitious, m e ch a n ica l p arro tin g that
so often renders cou nters ineffectual. It is o ften help fu l to e n c o u ra g e
the client to b e angry b e fo re you in itiate th e cou n terattack. After all,
the irrational beliefs h a v e caused all o f th e client's e m o tio n a l pain—
w h y shou ld they b e treated tenderly? Frequently o n ly an aggressive
attack can elicit a stron g e n o u g h em o tio n a l level to ov ertu rn a n irra­
tional thought.
Countering Techniques: Hard 93
/

M eth od
1. D evelop a list o f hard counters.
2. Help th e client c o u n te r forcefully. T he client sh ou ld practice the
c o u n te ra tta c k te c h n iq u e in front o f you, m o d elin g you r b e h a v io r
until a c o m p a r a b le level o f in ten sity is achieved. G radually shap e
th e client's resp onses toward a d ram atic attack with intensity and
energy.
3. T h e therapist can strengthen the counterattack by encouraging
clients to use physical exertion, progressively contracting their m us­
cles. Initially, clients counterattack w hile their m uscles are limp, then
slightly tensed, then strongly contracted. Frequently th e client's
em o tio n a l arousal parallels physical arousal.
4. Clients also stren g th e n th eir cou nterattacks th ro u g h voice m o d u la ­
tion, grad u ally sh a rp e n in g their voices and increasing th e volum e.
T he co u n te rsta te m e n t can at first b e said nasally and softly, then
n o rm a lly th ro u g h th e m outh, th en so m ew h a t loudly w hile filling
th e u p p e r part o f the lungs, then very loudly, with the lungs filled
w ith air. As w ith physical exertion, th e voice b e c o m e s an analogy
fo r th e client's level o f anger.

E x a m p le 1: The Story o f P hilip

Philip, a y o u n g m an, entered co u n selin g after attending a therapy
class I h ad given. Despite b e in g an accom p lish ed football player,
sturdy, a n d 6'5", h e was e x trem e ly shy with w o m en . The class had
h elp ed h im generally, b u t h e still cou ld n 't ask a w o m a n for a date. He
had n o difficulty b e in g assertive w ith m e n and handled m ale c o n ­
fro n ta tio n appropriately. After co m p letin g his cognitive m ap, w e iso­
lated o n e central belief: He th o u g h t w o m en w'ere weak, fragile
creatu res w h o m u st b e protected b y m en. He viewed h im self as a
c o m p le te lu m m o x , a B ab y H uey w h o could step o n the sensitive toes
o f th ese delicate people.
Philip's p erson al history indicated that his father had taught him
this belief. Apparently, the fath er feared th at his son's large size would
m ak e him to o aggressive with w o m e n — a p rob lem the father had
ex p e rie n ced h im s e lf w h en grow ing up. As a result, h e taught his son
to b e e x tre m e ly careful not to h u rt w om en. T he lesson had b e e n so
effective th a t Philip hadn't dated for tw o years and was so nervous
a ro u n d w o m e n that h e said practically n o th in g in th eir p resence for
 T h e N e w H a n d b o o k o f C ognitive T h e r a p y T e c h n i q u e s

fear o f bruising th eir delicate feelings. As a result, w o m e n rejected him

out o f h and as an e x trem e ly d u m b , th o u g h attractive, jock.
As w e w e n t th ro u g h th e usual cogn itiv e prelim inaries, th e client
develo p ed a long an d accu rate list o f c o u n te ra rg u m e n ts against his
co re thou gh t. However, w h en h e tried to use th e m h e w o u ld c o u n te r
so passively th at his arg u m en ts w ere ineffective. It was at this p oint
that w e decided to use counterattacking.
I in trodu ced th e te c h n iq u e as follows:

I am y o u r b o x in g c o a ch b u t I can 't get into th e ring w ith you

b e c a u s e th e ring is inside y o u r head. Your o p p o n e n t is th e core
b e lie f that w o m e n are e x trem e ly fragile. This b e lie f h a s b e e n
b ea tin g you up for years, m a k in g you in ord in ately sh y arou n d
w o m e n a n d preventing y ou from d ev elo p in g n o rm a l relatio n ­
ships. Even th o u g h you kn ow th e b e lie f is false, y o u h aven 't c o n ­
vinced yourself. You've hardly b e e n fightin g at all, an d o n th o se
rare o cca sio n s w h en you do fight, you do it so w e a k ly th at the
b e lie f easily overpow ers you. It keeps giving y o u a b la ck eye. You
m u st start defend ing y o u rse lf and fight b a ck w h e n e v e r this b e lie f
enters y o u r head. You can't ap p ease it. It's like d ealin g w ith any
o th er bully. T he m o re you give in, th e m o re fero cio u sly it will
c o m e b a ck n ex t tim e to b e a t o n you. You m u st start attacking th e
b e lie f as hard as you can.
Initially the thou ght will b e stron ger th a n y ou a n d will win the
fight. But if you persist, you will grad ually b e c o m e stron ger and
it will b e c o m e weaker. After a w hile you will b e g in to w in so m e
o f the lime, th en m ost o f th e time, until finally it w o n 't c o m e back
anym ore. Let's get started w ith y o u r first b o x in g lesson.

E x a m p le 2 : T he Story o f Bess
T h e follow ing e x a m p le co n ce rn s Bess, a client w h o w'as afraid o f
fainting. I d em onstrated the follow ing to h e r so th at sh e co u ld use
physical ex ertion in h e r counterattacks:

I would like you to d o som eth in g that will help you u nderstand
how to cou n ter with em otio n al energy. Let's pick a th ou g h t that
has caused you so m e problem s. You have said that you are afraid
that if you get an xiou s you will faint. Now, what w ould b e a goo d
co u n te r for th at thought? (Bess ch ose the counter, "1 n ev er have
fainted from anxiety!') Very good, a g o o d counter. But it's not
Countering Techniques: Hard 95
/

e n o u g h to simply have a goo d counter. How you say it is also very

important.
Now, ju st for practice, I w ould like you to say the counter, but
say it th ro u g h y o u r nose. I kn ow it seem s silly and feels a little
bit em barrassing, b u t please go ahead, say you r co u n te r nasally.
(Pause.) Very g oo d . Now 1 w ould like you to say the sam e
counter, b u t this tim e say it with y o u r m ou th . (Pause.) Now fill
th e u p p er part o f y o u r lungs and say it with m ore force. (Pause.)
That's fine. Now this tim e m a k e it as pow erful as you can. Fill all
y o u r lungs w ith air, m ak e you r b o d y rigid, and say the co u n te r
w ith as m u ch force as y ou can. (Pause.)
Excellent! That last o n e was a counter. All the others w ere not.
T h e w ords w ere right, b u t there was no fo rce b e h in d them. In the
future w h en I sp eak o f countering, I m ean th e last type. W h e n ­
ev er you counter, d o it as hard as you can.

C om m en t
This te c h n iq u e is useful in h elp in g passive clients, and it is the
treatm en t o f ch o ice for m a n y depressed patients. However, it m u st b e
used carefully, as it m ay b ack fire w ith especially an x io u s clients or
seriously distu rbed patients. Since the tech n iq u e accelerates clients'
e m o tio n a l level, it so m e tim e s causes anxiou s clients to b e c o m e even
m o re fearful o r psych otic patients to b e c o m e m ore agitated. In these
cases soft c o u n te rin g is m o re appropriate.
It is also crucial th at clients attack th eir beliefs rather th an th em ­
selves. Tell y o u r clients th at it can b e helpful if th ey call their irrational
th o u g h ts silly, stupid, o r ridiculous, b u t it's im po rtant not to call th em ­
selves n a m e s fo r b elie v in g them . Explain that they b eliev e the
th o u g h ts b e c a u s e th e y h av e b e e n taught to, an d that a n y o n e with
th eir sa m e b a c k g r o u n d a n d ex p erien ces would have believed them.
Although it takes a long time for most countering techniques to
w eaken irrational beliefs, counterattacking occasionally produces dra­
m atic reversals. I have seen several clients quickly remove beliefs they
had held for years b ecau se they b e c a m e intensely angry at their thoughts.
For exam ple, o n e client kept qu ittin g her jo b w h e n e v e r sh e h a d an
a n x iety attack. This w o m a n h ad b e e n th ro u g h years o f lo n g -te rm
therapy, b u t n o th in g seem ed to help— u ntil she got th o ro u g h ly fed up
w ith h e r situation. O n e aftern oo n , after sh e quit h e r third jo b that
year, so m e th in g u n u su al happ ened . Sh e ch an ged w h at she said to her­
self. Here's h ow s h e d escribed h e r self-talk:
 T h e N e w H a n d b o o k o f C o g n i t ive T h e r a t y T e c h n i q u e s

I'm really g ettin g tired o f this. H ere I a m again in th e sam e

place for the s a m e reason. I'm upset b e c a u s e I'm afraid I'll go
crazy and I th in k qu ittin g w ork will safeguard m y sanity. It's
really stupid! I'm m essing u p m y life, sp e n d in g a lot o f m oney,
w orry ing p eople w h o care a b o u t me. It w ould p ro b a b ly b e b e t­
ter if I ju st w e n t crazy. T h en I could spend m y w h o le life ru n n in g
aw ay like a chick en with its h ead cut off. This stinks! If I get
scared again, I get scared. So w hat, big deal! I'm tired o f ru nn ing.
I w on't run an ym ore! If I g o insane, the hell w ith it!

The next w eek s h e g o t a n o th e r jo b — th e b e st sh e could find. That

was 15 years ago. Sh e n e v e r left b ec a u se o f a n x iety again.

Further In fo r m a tio n
T h e relationsh ip b etw een stron g e m o tio n s an d co g n itio n s has b e e n
researched for o v er 3 0 years. S ee th e classic research o f S c h a c h te r and
Sin ger (Schachter, 1966; Sc h a c h ter & Singer, 1962) and th e ir m ore
recen t theoretical w o rk (M orow itz & Singer, 1995; S c h a c h te r & G az-
zaniga, 1989; Singer, 1995). Also review A rnold (1960) an d Plutchik
(1980).
A lbert Ellis has clients practice th eir c o u n te rs o n ta p e in o rd e r to
p rod uce vigorous, forceful, and persistent c o u n te rin g (see Ellis, 1998).
A rthur Freem an a n d A aron Beck h av e d o n e ex te n siv e w o rk o n an x i­
ety and p an ic disorders (Alford, Beck, Freem an, & Wright, 1990; Beck,
Emery, & G reen berg, 1985; Beck & Z eb b 1994; Freem an et. al. 1990).

C o u n t er a sser t io n

Principles

Assertion train in g has b e e n in practice for o v e r 3 0 years a n d alm ost

all therapists are fam iliar with the approach . A ssertion classes explain
the various c o m p o n e n ts o f the te c h n iq u e : h ow to use ey e contact, h ow
to express o n e s e lf spo ntan eou sly, how' to e x h ib it assertive b o d y p os­
ture, h ow to d e m o n stra te a w e ll-m o d u la te d voice. W h ile it takes
m o n th s o f practice to gain th e skill, s o m e p e o p le are ab le to m a k e per­
m a n e n t b e h a v io ra l changes, so assertion train in g can b e helpful. But
th e classes m ay n o t to u ch th e d eep er p ro b lem for s o m e clients, w h o
return to b e in g passive w h e n th ey finish th e classes.
Being assertive w ith others* is useful and can help clients im p rov e
Countering Techniques; Hard 97

th e ir relationships, b u t clients m ay find assertion m ore useful if they

are first assertive w ith themselves.

M eth od
1. Teach clients th e co re principles o f assertion training. Help them to
b e c o m e assertive w ith them selves b efo re th ey practice b ein g
assertive w ith others. For exam ple, tell a patient w h o criticizes h im ­
s e lf b e c a u s e h e m ad e a b ad investm ent, "There are four different
w ay s y ou ca n h a n d le y o u r mistake. You can be:
(a) Passive. Ign ore y o u r m istake and pretend it didn't happen. This
is not useful b e c a u s e you will p ro b a b ly keep m ak in g th e sam e
m istak e an d will not reach y o u r financial goals.
(b) Aggressive. Attack yourself. Blam e y o u rse lf unm ercifully for
b e in g so stupid for sp en d in g th e m oney. This approach will cause
pain, low er y o u r self-esteem , and m ak e it less likely that you will
take an y in v e stm en t c h an ce s in th e future.
(c) Passive-aggressive. You can get back at y o u rse lf indirectly by get­
ting drunk, overeating, a n d in ten tion ally m a k e w orse invest­
m ents. This is d am agin g; n ot o n ly d o you not reach y o u r goals,
b u t y ou h av e also played hide and seek with y o u rse lf so you are
no lo n g er sure w hat m istake you h av e made.
(d) Assertive. Be h onest with you rself that you m ad e a mistake.
Identify the error as o n e o f ju d g m en t rather th a n o n e o f ch arac­
ter. Specify th e n atu re o f th e error, i.e., 'I accepted w h at th e agent
said w ith o u t checkin g it out.' D escribe w h a t you will try to d o dif­
ferently in th e future, i.e., 'I will always ch eck future investm ents
w ith an in d e p en d en t source.' This ap p roach m akes it m ore likely
that you will reach y o u r goals w ith ou t having all the negative,
distracting e m o tio n s stirred up b y self aggression."
2. Practice. M a n y practice tech n iq u es m ay b e effective, b u t the most
useful o n es for self-assertion are ro le-p la y in g and taped rehearsal.
(a) Role-playing. M a k e a list o f typical con flict situations with w hich
th e client is faced. However, unlike in standard assertion training,
the con flicts sh ou ld b e internal, n o t external. Then have the
client practice th e fou r different types o f internal responses out
loud. Ask th e client to notice th e different em o tio n a l feelings that
each ap p roach produces.
(b) Taped rehearsal. Clients practice their self-assertive responses on
a tape recorder until they are satisfied w ith their content and tone.
3. Inner Teacher. As th e last part o f self-assertion training, d e scrib e th e
 T h e N e w H a n d b o o k o f Co g n i t i v e T h e r a p y T e c h n i q u e s

a n alog y o f th e in n e r tea ch er in sufficient detail (see th e sectio n on

self-instru ction in ch ap ter 2). Help y o u r clients find th eir teachers,
identify their origins, and, if necessary-, h elp th em fire th eir old
teachers an d hire new ones.

E x a m p les
O n the outside, m ost c o c a in e addicts are e x tre m e ly aggressive. They
will fight the world to get their n ex t hit: th e police, th eir sp o u se (if
th ey still have one), th eir mother. T h ey will steal, em bezzle, con,
assault, a n d sell their bodies. O n e addict told m e he w ould sell his soul
for a gram o f c o c a in e if a n y b o d y w o u ld ta k e h im up o n the offer. T hey
are clearly aggressive p eople w h en th ey have th e ir craving, w h ich is
m ost o f the time. O n th e outside th ey are a n y th in g b u t passive.
But o n th e inside m a n y addicts are w im ps. Burt, a client o f m ine, was
a c o ca in e addict w h o rarely resisted his craving. W h e n e v e r his desire
welled up h e yielded, cavin g in totally to th e im p u lse w ith o u t putting
up a n y resistance. W h e n the craving ordered, h e obeyed, a n d m eekly
su rrend ered w ithou t a whimper.
Burt need ed to learn self-assertion. 1 told him to lo o k at his crav­
ings for drugs in th e s a m e w ay h e would im ag in e b e in g assaulted b y
a b u lly— an interior b u lly w h o had b e e n b e a tin g him u p fo r 10 years.
He had n ev er resisted this bully, n e v e r learned to fight back. He w'ould
accept such excu ses as, "O n e hit can't hurt me. I c a n c o n tro l m y use. 1
need it to feel better. I'm addicted b e c a u s e 1 had a rotten ch ild h ood .
M y em o tio n a l p rob lem s cau se m e to use to o much."
I told h im to start fighting the bully. Tell h im off. G et assertive. He
end ed up writing d ow n th e follow ing assertion and carry ing it in his
wallet. It said:

I will n ev er stop at o n e hit, n ev er have, n e v e r will. Since I've

b e e n using, m y life has b e e n totally o u t o f control. M y em o tio n a l
problem s or rotten ch ild h o o d o r a n y o th e r reason I d re a m up is
just a n o th e r e x cu se to use drugs. T he real reason I keep u sin g is
b ec a u se I a m a rom ping, stom ping, tra m p in g ju nkie. If I don't
like w h at m y add iction brings me, I can w ork o n it, get help, stop
using, and turn m y life around. If I don't w ant to w o rk o n it th en
I m ust accept the co n seq u e n ce s. It's m y choice. So ch o o se! Every­
thing else is just bullshit.

S o m e clients are the opposite o f Burt: passive on th e outside b u t h o r ­

ribly aggressive o n the inside. A n o th e r client, Sara, was an extrem ely
Countering Techniques: Hard 99
/

passive person. Her friends described her as o n e o f the m ousiest people

im aginable; sh e e m b o d ie d meekness. Sh e sp o ke in a w h im p er and c o n ­
stantly had to b e asked to sp eak up. But incredibly, in h er conversations
with herself sh e sp o ke in a m onstrous, ruinous way. Her self-attack was
so vicious th a t it was surprising that she stood it. O ne time, after lock­
ing h er keys in her car, sh e sh ou ted at the top o f her voice, "You w orth­
less, syphilitic, bitch, slut, cunt!" Sh e told m e that had a n y o n e else
sp o ken this way to her, sh e would have tried to pluck her eyes out, but
sh e continually accepted these m o n u m en ta l obscenities from herself.
It was useless to tea ch Sara to b e assertive w ith others w h en she
was b ea tin g th e w o rth out o f h e r self. I told h e r sh e was w rong to treat
h erself so badly. S h e had rights like a n y o n e else and was a w orthw hile
h u m a n b ein g , deservin g o f respect and kind n ess not ju st from others
but, m o r e importantly, from herself.
Sara's self ob scen ities w ere m ak in g her miserable. A lthou gh getting
alon g with o th ers was very im portant, it was far m o re im portan t for
h e r to get a lo n g with herself. Sh e needed to learn self-courtesy, good
se lf-m a n n e rs, a n d w e ll-b eh a v ed self-talk.
Sara practiced her internal dialogue until sh e got it right and it
helped. Sh e n ev er had to d o a n y h o w -to -b e -a s s e r tiv e -w ith -o th e r s
training b e c a u s e s h e didn't need it. O n c e sh e b eg an treating herself
w ith respect, sh e found it fairly easy to stand up for h er rights in front
o f others.

C om m en t
Sara's ca se p oin ts out th e problem w ith assertion training and
m a n y o th e r tech n iq u es that sim p ly aim to ch an g e how clients behave.
Clients act as they th in k and think as th ey act. T hey can c h a n g e their
b e h a v io r perfectly and follow a prepared script, b u t th ey may revert
b a ck to their old w ays very qu ickly if th e y h aven't changed th eir atti­
tude.
Burl was aggressive tow ard others b ec a u se h e believed h im self a
hero. A ccord ing to his self-d escription, h e was G od's favorite, a special
crea tion fo r w h o m a little thing like drugs cou ld n 't b e a problem . This
attitu d e kept him assaulting others and refusing to adm it that he
co u ld n 't h a n d le cocain e. Similarly, Sara was passive externally b ecau se
in tern ally s h e hated herself. How could sh e feel oth erw ise w h e n she
accepted th e v iciou sn ess o f h e r ow n attacks?
Clients' passivity o r aggressiveness m ay b e rooted in th eir s e lf-c o n -
cept. How c a n o th e r p eople respect th em w h en they don 't respect
 ________ ___________T ii f N f.w H a n d bo o k of Cq g n jiiv e T h e r a p y T e c h n iq u e s

th em selves? How can th e y like th em selv e s if th ey h a te e v e ry b o d y

a rou n d them ? T heir attitu d e a n d b e h a v io r c o m b in e a n d revolve
arou n d each other. It's a co n sta n t feed b ack lo o p ; o n e affects th e other.
It is im p o ssib le to w o rk o n o n e and leave th e o th e r u n ch a n g ed . If
clients are passive, th ey n ee d to resolve th eir b e lie f th a t th e y are
u n w o rth y o r inferior. If th ey are egotistically aggressive, th e y n ee d to
e x a m in e w h y they b e lie v e them selv es so superior.

F u rther In fo r m a tio n
T he classic w orks on assertion train in g are well know n. M o st
fam o u s is Your Perfect Right (Alberti & Em m ons, 1995). Review the
authors' professional ed ition (Alberti, 1987) and th eir m a n u a l for
assertion trainers (Alberti, 1990, w ith 1995 supplem ent). A n ew revi­
sion is availab le o f a w e ll-k n o w n assertion b o o k for w o m e n (Butler,
1992). You m ay find it useful to review an assertion b o o k w ith a strong
cognitive c o m p o n e n t (Paris & Casey, 1985) a n d a client h a n d b o o k o f
assertion used b y m e n ta l h ealth w'orkers (Rees & G rah am , 1991).
H auck describes several assertion strategies h e uses in a cogn itive
fram ew ork (Hauck, 1992, 1998).

D ispu t in g an d C h a llen g in g

Principles

R ational em o tiv e b e h a v io r th erap y (REBT) em p loy s a m o re fr e e -

floating style th an o th e r c o u n te rin g te c h n iq u e s presented in this
chapter. In REBT, th e c o u n se lo r focu ses o n irrational th ou g h ts as th ey
o c cu r in th e client's conversation , and clien t a n d therap ist w ork
tog eth er to dispute and ch allen g e false thinking. T h e style e n a b le s the
c o u n selo r to stay in to u ch m o r e fully w ith th e client's im m e d ia te c o n ­
cerns, b ec a u se the therapist follows the client's agenda. In contrast, the
standard cognitive restru ctu ring a p p ro a c h is m ore stru ctu red and
m ore closely follows the therapist's regim en.
Traditional REBT uses a S o cra tic a p p ro a ch in w h ich the therap ist
directs the client's a tten tio n to a series o f logical q u e s tio n s lead in g to
t h e faults u nderlying the client's thinking. T h e c o u n s e lo r p ro b e s freely
into key areas o f irrationality, reflects and reinforces the client's
rational discoveries, a n d provides inform ation.
REBT is used in cognitive restru ctu ring th erap y as an a d ju n ct rath er
Countering. Techniques: Hard 101
/

th a n as a b asic tech n iq u e. It usually acco m p a n ies other, m ore struc­

tured approaches.

M eth od
1. Keep in m in d that, althou gh unstructured, REBT does use certain
estab lished c o m p o n e n ts at different stages o f the therapeutic
process.
2. Help the client focu s o n the central irrational th o u g h t causing the
anxiety, guilt, anger, or depression.
3. P robe in to th e ev id en ce against the belief.
4. D ispute th e client's catastrop h izin g (i.e., "it's terrible, horrible, and
catastrop h ic th at . . . ") and self-d em an d in g aspects o f th e client's
th in k in g ("I must, o u g h t to, and sh ou ld . . . ").
5. In m ost cases don't give co u n te rs directly. Rather, use incisive q u es­
tion s to help th e client discover his o r h er ow n counters.
6. E n cou rag e th e client to dispute and challenge irrational thoughts
w h e n e v e r th ey occur. S o m e form al practice each day is suggested.
A tape recorder is o ften helpful (see Ellis, 1998).
7. You m ay find it helpful to develop a m ental set for the use o f REBT
b y listening to a th era p e u tic session by A lbert Ellis or o n e o f his col­
leagues.

E x a m p le
Exam ples o f th e REBT style are so n u m ero u s in th e literature that
a n o th e r e x a m p le w ould b e superfluous. I reco m m en d Ellis's books,
Better, Deeper, and M ore Enduring Brief Therapy, (1995) and Growth Through
Reason (1971), w h ich presents seven v e rb a tim cases in REBT. Even b et­
ter, how ever, are recordings o f REBT th erap eu tic interviews, w hich can
b e ordered from th e Albert Ellis Institute for Rational Em otive B eh av­
ior Therapy, 4S E. 6 5th St., New York, NY 10 02 1 -6 5 9 5 (o rd ers@ rebt.org).
T h ese tapes are from the professional ta p e library and are available
o n ly to qu alified therapists.

F u rther In fo r m a tio n
T h e literature o n REBT is truly extensive. The catalog from Ellis's
Institu te fo r Rational Em otive T herapy lists th e m a jo r publications. If
th e read er is not fam iliar with REBT, th e following sou rces provide a
 T h e N e w H a n d b o o k o f C ognitive T h e r a p y T ech n i q u e s

c o m p reh en siv e review: Ellis (1962, 1971, 1973, 1975, 1985, 1988a, 1988b,
1991, 1995, 1996, 1998); Ellis and A b ra h m s (1978); Ellis and Dryden
(1996); Ellis and Grieger (1977); and Ellis a n d H arper (1961, 1975, 1998);
Ellis and Lange (1995); Ellis and W h ite le y (1979); Ellis, Wolfe, a n d M o se­
ley (1966); Ellis and Yeager (1989); Ellis and colleag u es (1996).
For REBT m e th o d s with m o re specialized client p op u lation s, se e the
following: for children, H au ck (1967) and Ellis, Wolfe, and M o se ley
(1966); marital, Ellis a n d H arper (1971), Ellis, Sichel, Yeager, DiMattia,
and DiGiuseppe (1989); sex therapy, Ellis (1975); addictions, Ellis and
colleagues (1988 ) and Ellis and Velten (1992).

F o r c in g C h o ic es

Principles

T here is a truth that m a n y ex p erien ced therapists h a v e learned , but

d on 't often m e n tio n to th e public. W h ile it u su ally takes at least 10
years o f e x p e rie n c e with th o u sa n d s o f clients to discover, m ost th era ­
pists are relu ctant to discuss it in their b o o k s, w rite a b o u t it in their
journals, or m en tio n it to th eir colleagues. It is o n e o f th e m o r e regret­
table, sad der aspects o f b e in g a therapist a n d it causes a great d eal o f
stress to m a n y m en tal health professionals.
W h at is this truth? S im p ly this: Clients don't change until they have to.
M ost clients c h a n g e o n ly in small, painful steps if th ey c h a n g e at all;
no m a tter w h at te c h n iq u e s therapists give them , m a n y clients will
c o n tin u e to suffer throu g h their p ro b lem until so m e crisis forces th em
to m a k e a choice. Even th en , during th e crisis, clients will avoid c h o o s ­
ing for as long as possible, and will escap e from c h o o s in g to c h a n g e
for as long as th ey can. T h ey will p o s tp o n e th e in ev ita b le u ntil th ey
absolutely, positively c a n n o t avoid it an y m o re. This is sad, b e c a u s e
clients en d up en d u rin g additional e m o tio n a l pain and w aste addi­
tional tim e unnecessarily.
A g o o d m e ta p h o r I give m y clients in e x p la in in g th e process o f
ch a n g e is th at o f a river. I a sk th em to picture th eir beliefs as if t h e y
w ere in a river flow ing tow ard th e o c e a n : as lo n g as th eir cogn ition s
a rc flow ing freely a lo n g with all th e currents, w h irlp ools, an d eddies
o f their life exp erien ces, they are h e a lt h y But as s o o n as th eir c o g n i­
tions b e c o m e rigid and custom ary, th e river b e c o m e s stop p ed up and
they b e c o m e stagnant. T hev stop grow ing a n d ch an gin g . T h e dam
they build b e c o m e s so strong that o n ly e x tr e m e pressure will b r e a k it.
Countering Techniques; Hard 103
/

Clients will d o ev ery th in g th ey can to avoid c h o o sin g to break

th ro u g h th e d a m and c h a n g e th e ir beliefs. Like a river, th ey will try to
flow a ro u n d beliefs b y overflow ing the banks. O n ly w h en all escapes
are b lo ck ed and th e river has no place left to go, o n ly w h en the pres­
su re gets stron g en o u g h , will th e d a m b reak a n d the client's cogn itions
flow freely again.
W e th erap ists o ften m ish a n d le b lo ck ag e problem s. We try to im m e ­
diately red uce th e pressure against th e dam to help the client feel less
a n x io u s o r frustrated. W e d o this with g o o d intentions; w e w an t to
m a k e o u r clients feel better. W e te a c h relaxation and prescribe tran­
quilizers and antidepressants. We hospitalize th em ; w e allow their rel­
atives to visit, to co m fo rt and so o th e— all are attem pts to reduce their
pain. But this c o m fo rtin g and so o th in g m ay b e accom plished at the
cost o f keeping so m e clients from b rea k in g through th eir dams. Pres­
sure, stress, and pain are not alw ays bad. T hey show patients that
s o m e th in g is wrong, so m eth in g is hurting. Clients n eed to identify the
hurt a n d correct it, not ju st tranqu ilize it.
T h ou g h it is difficult, it's often best not to push o u r clients' hurt and
pain aw ay as qu ickly as w e can. Despite th e e m p a th y that w e feel, w e
m a y h elp th em m o re b y allow ing th em to feel the pain— this will pro­
pel th em to c h o o s e to b r e a k through th e dam .
Pure w earin ess develops the streng th needed to attack the cause o f
p ro b lem s rath er th a n ju st th e painful sym ptom s. W h e n clients are
ready, therapists sh o u ld help by b lock in g escap e routes; refusing to
tran qu ilize all their pain helps to prevent them from ru n ning from the
p ro b lem to get tem p o rary relief. Four principles su m m arize th e essen­
tial c o m p o n e n ts o f forcing th era p e u tic change.

M eth o d 1
1. T he old, d am ag in g p erception m u st b e painful for clients. It must
b e a reservoir o f anxiety, depression, o r anger, creating a condition
from w h ich clients w an t to escape.
2. Clients m u st b e aw are o f a reasonable, alternative cognition, a new
perception. This a lternative B must b e im p o rtan t a n d relevant so
that th e client will seek it after the old cognition has b een
destroyed.
3. Clients m u st feel trapped by their old thought. They m u st c o m e to
b e lie v e th at the o n ly w ay out o f the trap is to c h o o s e to change
th eir attitude. T he pain associated with th e old b e lie f sh o u ld not be
red uced o r m a d e so to lera b le throu g h drugs or o th e r am eliorative
 Th e N e w H a n d b o o k o e C o g n i t i v e T h e r a p y T e c h n i q u e s

strategies th a t it is possible for clients to hold o n to th eir m istak en

belief.
4. It is essential that therapists d o n 't add to th e client's p rob lem . The
n atu ral c o n se q u e n c e s o f th e old attitu d e sh o u ld trap th e clien t in
th e p resent situation. T h e therap ist shou ld n o t place a n artificial
im p ed im en t in the way.

M eth o d 2
1. Find a co re m istaken b e lie f th a t is g e n era tin g a m a jo r sh a re o f the
client's pain. For exam ple, th e client m ay b e lie v e his or h e r p u rpose
in life is to fulfill im aginary "oughts," "musts," a n d "shoulds.
2. C ou nter the client's m istaken beliefs, in tro d u cin g as m a n y p e rsu a ­
sive con trary view s as possible. For exam p le, "ou g h ts" and "m usts"
don 't exist ex cep t in th e m in d s o f h u m a n beings. T h e world ju st is.
It has no "oughts," "shoulds," o r "m usts" in it.
3. C ontrive a situation or exercise, covert or in vivo, in w h ic h the
client faces o n ly tw o choices: b elie v in g in th e old p e rce p tio n or
shifting to the new. For exam p le, suggest a situ ation in w h ich two
"m usts" o f e q u a l strength o p p o se e a c h other, and b o t h p ro d u ce
strong negative effects.
4. Do y o u r b est to help y o u r client face th e conflict. If y ou e n c o u ra g e
or provide an escap e rou te that d o esn 't req u ire clients to c h a n g e
th eir beliefs, they will lak e it.
5. At th e peak o f th e conflict, identify th e shift to b e taken and
en co u ra g e the client to m ak e th e shift.

E x a m p le 1: The Story o f K ate

Kate was m arried to a d ru nken, drugging, abusive, p h ilan d erin g
h u sb a n d for 15 years. He sp en t days aw ay from h o m e w ith o th er
w o m en , neglected th e ir children, cou ld n 't hold d o w n a job, physically
ab used her m a n y times, a n d g am b le d all o f h e r m o n e y away. His
m a le v o len c e was ob v iou s to everybody. He w as h ated b y all Kate's
friends and relatives, w h o co n sta n tly advised h er to leav e him . U n fo r­
tunately, sh e could never b rin g h erself to d o it.
Sh e h ad a th o u sa n d excuses. Sh e b la m e d h erself an d kep t h o p in g
that sh e could straighten h im out. S h e w e n t to m arital c o u n s e lin g b u t
h er h u sb a n d refused to attend. Sh e tried to get h im to a tten d AA
m eetings, b u t h e w ent just o n c e an d left, say ing h e didn't like it. She
left self-h elp pam p h lets a ro u n d the h o u se h o p in g th a t h e w o u ld read
 Countering Techniques; Hard
/ 105

th e m b u t h e threw th e m away. W h e th e r h e was arrested, fired, o r had

sp en t th eir m oney, sh e would accept him back as if n o th in g had h a p ­
pened.
It was o b v io u s to all w h at sh e needed to do. He was a m on strou s
h u sb an d , a n d since sh e cou ld n 't ch an g e him, sh e eith er had to accept
the h o rrib le m arriage o r leave. Everyb od y sh e knew, m ale and female,
y o u n g and old, told her to leave, but sh e kept trying to escap e the
o b v io u s b y g o in g to different doctors, ministers, o r therapists. Sh e read
ev ery p op p sych ology b o o k on "h o w to fix y o u r marriage," "how to
straig h ten out y o u r husband," "h o w to b e a total woman," "how to be
a sen su al wife," "how to save a failing marriage." N othing helped and
things got worse.
S h e had a 1 0 -y e a r-o ld so n n a m ed Billy w h o suffered along with
her. O n e night Kate's h u sb a n d c a m e h o m e d ru n k again, and started to
yell at h e r b e c a u s e th e d in n e r was cold. The yelling b e c a m e louder
a n d lou d er a n d Billy overh eard the fight as h e had overheard m an y
fights before. He saw his fa th er hit his m other, which had also hap­
p e n ed before, b u t this tim e Billy cou ld n 't stan d it and ju m p e d on his
father’s back, hold ing on, trying to protect his m om . His father threw
Billy o ff and Billy fell dow n a flight o f stairs. He lay u n con scio u s at the
b o tto m w h ile his father ru shed out o f the h o u se cursing. Kate called
the a m b u la n c e and to o k Billy to th e hospital. He had a mild co n cu s­
sion.
O n e w ould th in k this w ould h av e b een th e last straw for Kate, but
it wasn't. S h e d en ied that h e r h u sb a n d was to blam e. W h e n he cam e
h o m e several days later, sh e accepted h im back an d told h e r friends it
had ju st b e e n an u n fo rtu n a te accident.
Her friends knew better. O n e o f th em called social services and
rep orted th e incident, and all o f th e o th e r a b u se that had b e e n going
o n for so m a n y years. Social services investigated and found th e hus­
b a n d to b e a n u nfit and d an g erou s parent. T he co u rt ordered him to
leave th e h o u se an d forbid him to see the children until h e had totally
stop p ed all drin king and dru gg ing for o n e year, had successfully c o m ­
pleted an a n g e r -m a n a g e m e n t class, and had received individual th er­
apy. He could o cca sio n a lly visit his w ife and children if h e com plied
w ith all o f these orders.
At th e s a m e time, social services told Kate that sh e m u st not allow
h e r h u sb a n d to live at h om e. If sh e violated the ord er it would be
gro u n d s for th em to send her children to a foster home.
But Kate still w ould n't choose. Sh e told the w orkers sh e w ould b e
willing to e n te r co u n selin g treatm en t, g o to classes, o r d o anyth ing
1Q6 T h e N e w H a n d b o o k o f Cognitive T h e r a p y T e c h n i q u e s

else so that h e r h u sb a n d could r e m a in in their h om e. S h e tried to fight

th e decision legally, w rote letters to th e local paper, h ired h e r ow n
lawyer, and tried to sue, but n o th in g worked: T h e child p rotection
a g e n cy and th e courts would h av e n o n e o f it.
Kate ignored the order. S h e sn e ak ed h e r h u sb a n d b a ck into the
h ou se and hid him w h e n e v e r social service p erson n el visited, b u t this
b e c a m e increasingly difficult as th e social w o rk ers b e c a m e suspicious,
and w ould so m etim es arrive u n a n n o u n ce d . T h ings w ent a lo n g this
w ay for so m e time, until o n e Su n d ay afternoon .
Kate was h o m e alone. Her children w ere visiting th eir g r a n d m o th e r
a n d h e r h u sb a n d was on th e o th e r side o f tow n d rin k in g b e e r and
w atching football w ith so m e buddies. S h e was sitting a lo n e in th e liv­
ing room , th in k in g a b o u t all o f h er problem s. Sh e realized th a t e v e n ­
tually social service w ould m a k e an u n ex p ected visit a n d discov er her
h u sb a n d living at hom e. Sh e w ould either lose h e r h u s b a n d o r lose
h e r children. Sh e felt trapped, panicky, and in c o m p le te despair; she
seriously co n tem p la ted suicide, b u t qu ickly a b a n d o n e d the idea. After
panicking all afternoon, sh e su d d en ly ju m p e d up, w e n t to th e phone,
and m a d e three p h o n e calls. Sh e called her h u sb a n d an d told h im that
he had to leave th e h ou se im m ediately. S h e p h o n e d th e p olice and
had a restraining o rd e r taken o u t in case h e c a m e b y Finally, she
called h er law yer and told h im to file im m ed iately for a divorce.
Later, s h e told m e that S u n d a y had b e e n the tu rn in g point. Sh e
en d ed the w h o le th in g th a t o n e aftern oo n , and n e v e r w e n t b a ck on
her ch o ice o r d o u b ted it for a m om en t. S h e follow ed th ro u g h o n all
her threats. Her h u sb a n d did v io late th e ord er b u t w'as p rosecu ted and
placed o n probation . U p o n receiving a th rea ten in g letter from him ,
sh e im m ed iately called his p ro b a tio n officer. Sh e o b ta in e d h e r d iv orce
and started to date attractive, responsible, n o n d rin k in g m en. She
n ev er regretted h e r choice, n ev er felt sorry for her e x -h u s b a n d , and
n ev er d o u b ted h erself for a m o m e n t a b o u t leaving th e relationship.
And all this occu rred o n e u n eventful S u n d a y a fte r n o o n w h en Kate
chose to break through her dam.

E x a m p le 2 : The Story o f D aniel

T h e case o f a n o t h e r client, Daniel, fu rth er illustrates th e process.
Daniel was a person w h o feared g o in g crazy, and this fear d o m in a ted
his life. He was afraid that s o m e d a y his e m o tio n s (particularly ten sio n
and anxiety) w ould b e c o m f so pow erful th at th ey w ould m a k e him
go crazy. He w asn't sure exactly h o w stress c o u ld m ak e o n e 's b ra in
 Countering Techniques; Hard
/
107

snap, b u t h e w as certain it could h a p p en . He vividly pictured h im self

lock ed in a p ad d ed cell, con fin ed in a straitjacket, lying in the back
ward o f a dirty, b ro k e n -d o w n , m en tal hospital, scream in g day after
day, m o n th after m o n th , w ith n o b o d y in the world giving a dam n. It
terrified him.
He did ev eryth in g h e could im ag in e to avoid losing his mind. He
visited a d ozen doctors, tried all kinds o f tranqu ilizers an d avoided
w a tc h in g a n y m ov ie o r TV show o r reading a n y novel that discussed
in sa n e people. He tried to keep his fear from escalating by living alon e
in his h o u se so th at others cou ld n 't upset him. He spent m ost o f his
day w a tc h in g m ild sitcom s o n TV. He didn't like them, but at least they
didn't m a k e him afraid.
Still, n o m a tter w h at h e tried he would still occasion ally get a n x ­
ious, an d w h e n th a t h a p p en ed h e w o u ld rush to th e p h o n e and call
his therapist, d e m a n d in g ad m ission to the local hospital. T h ere he
w ould b e sedated until th e fear w ent away. He'd had h im self adm it­
ted five tim es in tw o years.
Late o n e w inter n igh t Daniel was lying o n the co u ch with the TV
on, half asleep b u t still vag u ely aw are o f th e sights and sou nds around
him . Su d d en ly h e started to feel anxious. He sat up, concerned , and
look ed a ro u n d for th e cause. Finally h e noticed that the television was
tuned to a talk sh ow ab o u t e x -m e n ta l patients w h o were describing
th eir e x p e rie n ces in full and gory detail. He qu ickly got up and
ch an g ed th e chann el, b u t it was too late; h e had heard too m uch. He
was u n a b le to block his fear, and it quickly grew into a full-fledged
p an ic attack.
He tried ev eryth in g h e could to red uce it. He rushed to his m edi­
c in e c a b in e t to take so m e tranquilizers, but the b ottle was empty. He
r e m e m b e re d h e had hidden a reserve b o ttle in case h e ev er ran out,
b u t he'd forgotten w h e re it was. He rum m aged desperately through all
th e cabinets, closets, and b oxes in his apartm en t, b u t h e could n't find
th em anyw here.
He w e n t to em e rg e n cy plan #2. Despite th e late hour, he called his
therapist b u t fo u n d n o answer, then rem em b ered that h e was out o f
tow n. He tried p h o n in g so m e o f his past therapists, but reached
a n sw erin g m ach in es o r found that th eir phones had b e e n discon­
nected. He tried calling tw o different 2 4 - h o u r crisis lines, b u t b o th told
him n o t to w o rry a b o u t it. He scra m b led for so m e o n e else to call,
k n o w in g that th o u g h h e had lost his friends th rou g h th e years, h e still
had s o m e relatives w h o m ight help. He p h o n e d th em a n d w oke them
up, b u t after years o f h earing D aniel cry wolf, th ey w ere tired o f his
 T h e N e w H a n d b o o k oi C o g n i t i v e T h e r a p y T e c h n i q u e s

panics. T hey didn't appreciate b ein g w o k en up in th e m id d le o f the

night, and told h im h e w ould h av e to h a n d le the p ro b le m himself.
His fears rising to a m a x im u m , h e ru shed o u t o f th e hou se, ju m p e d
into his c a r and drove as fast as h e could to the e m e r g e n c y r o o m o f
th e c o u n ty hospital. But w h en he arrived h e found th a t th e re had
b e e n an ice blizzard on o n e o f th e m a jo r freew ays an d tw e n ty -fiv e
cars had b e e n involved in a pileup. T he h osp ital sta ff was ru n n in g
a rou n d trying to help the accid ent victim s an d h e was told th a t th ey
didn't h av e tim e to see him.
So th ere h e was— trapped. H e h ad n o p lace to go, n o o n e to call,
n o b o d y to turn to. Deciding that since h e was g o in g to p a n ic h e m ig h t
as well do it at h o m e , h e g o t into his c a r and d rov e back to his apart­
m ent. He sat in his living r o o m chair, turned the lights off, and waited
for his brain to snap and to go insane. He sat th ere for tw o h ours, let­
ting th e waves o f p a n ic flow o v e r him.
Later o n Daniel d escribed w hat had h a p p e n e d to h im as h e sat
waiting. (This dialogue is recon stru cted from his report.)

I was sitting there with waves and w aves o f panic, exh au sted ,
terrified, w ith n o place to g o and no o n e to turn to. I was w ait­
ing to g o crazy. But su dd enly o u t o f now here, I ju m p e d up and
started to talk to m y se lf o u t loud. I talked lou d er an d lo u d e r until
I was sh o u tin g at myself. I said, "W h o th e hell cares i f I g o insan e?
It could n't b e a n y w o rse th a n w h at I'm feeling now. M y life has­
n't b e e n w o rth a b u ck et o f shit for the last ten years. I'm not m a r­
ried, I don 't h av e a n y girlfriends, I can't hold a jo b , and I've b e e n
on m edical disability for the last 10 years. I h av e n o friends, m y
relatives can't stand me, a n d m y therapists are tired o f m e. So
w h o the hell cares? This isn't a life. I don 't h av e to fear losing
anything, b e c a u s e I have n o th in g left to lose. T h ere is no reason
to protect m y se lf a n y m o re. It d o esn 't m a tter w h at precau tion s I
take— th ey don 't work, so w h a t difference does it m a k e? I've had
it. T h e hell with it all. If I'm g o in g to g o insane, I'm g o in g to go
insane, b u t I'm n o t g o in g to escap e a n y m o re. T h ere is n o place
to esca p e to, anyway. If I'm u ltim ately g o in g to end up a loony, I
m ight ju st as well h av e a g o o d tim e b e fo re I do!"

Afterwards h e got up, w alked o u t o f th e h o u s e an d w e n t to an a ll-

night restau rant w h ere h e had the biggest, g o o ie st pizza h e c o u ld find.
He ate th e w h o le thing, th e n w e n t to a n a ll-n ig h t m o v ie an d didn't
return h o m e until dawn.
This was Daniel's turning point. H aving b e e n faced w ith a crisis from
w h ich there was n o escape, D aniel ch ose an alternative B a n d h e n ev er
 Countering Techniques: Hard
/

look ed back. His panics subsided, and h e tried to live life to the fullest.
He b e g a n to travel and took so m e classes in school. He looked for a jo b
and started to date. S o m e tim e later h e found his hidden pills, but
im m ed ia tely threw th e m away in disgust. At th e en d o f a year h e was
a totally different person and alm ost n ev er got anxious. All o f this can
b e traced back to th at w inter n igh t w h en he chose to break through his dam.

C om m en t
T h ese tw o stories are rep resentative o f m a n y cases. How could Kate
hold o n to su ch a terrible relationsh ip for all th o se years and then,
suddenly, im m e d ia tely e n d th e relation sh ip w ithou t a n y regrets or
b ack w a rd glan ces? How could Daniel, after years o f fear, break
th ro u g h in o n e d ra m a tic ev enin g ?
Possibly th e b e st ex p la n a tio n for b o th m e ta m o rp h o se s is th e prin­
ciple m e n tio n e d in the b e g in n in g o f this essay: People don't choose to
change until they have to. O n c e th ey are forced to m a k e th e decision, they
rarely lo o k back. T h ey m ay h av e stayed rooted in th eir problem s for
years, favoring palliatives and p ain o v e r th e big decision, b u t w hen
th ey are c o m p le te ly trapped and have n o escap e left, they create their
ow n change.
The therapist m ay w o n d er w h en to use this technique. Our experi­
e n c e has found that it shou ld b e used after the o th er CRT techniques
h av e b e e n taught. Clients should know that it is their beliefs, not their
env iron m en ts, that are causing em o tio n al distress; they should have
identified the specific thou gh ts causing the distress, and they should
have a very clear idea o f w h at replacem ent b elie f is rational and realis­
tic. T h en and only then will this tech n iqu e lead to constructive changes.
Obviously, this te c h n iq u e sh ou ld n o t b e used with clients w h o have
suicidal ten d en c ies o r w h o are likely to cause physical h arm to th em ­
selves o r o th ers in resp o n se to their em o tio n a l pain.
In theory, forcin g ch oices is an o x y m o ro n . If choice is forced, it is
n ot a choice. T h e in te n t o f th e te c h n iq u e is not to elim in ate all choices
b u t to n a rro w th em to two: c h o o sin g to put up with the p rob lem or
c h o o sin g to change.

F u rth er In fo r m a tio n
Existential p sy ch oth erap y was an early p rom o ter o f the im p o rtan ce
o f clien t c h o ic e and self-responsibility. Clients are en cou raged to take
th e n ecessary risks to try to actualize th eir potentials (Frankl, 1959,
1972, 1977, 1978, 1980; May, 1953, 1981).
110 T u t N e w H a n d b o o k or C o g n i t i v e T h e r a p y T e c h n i q u e s

* v
W illiam Glasser, fo u n d e r o f reality therapy, develo p ed a psy ch oth er­
apy g rou n d ed o n client choices (Glasser, 1998). He asserts that w e
c h o o se all w e do and that acting a n d thinkin g are v o lu n tary activities
(Glasser 1989, 1998).

C r ea t in g D isso n a n c e

Principles

Clients unify th eir th o u g h ts coherently, t h o u g h n o t necessarily c o r ­

rectly. If th ey b eg in with an absu rd ly irrational assu m p tion , th ey then
interpret all su b seq u e n t data in light o f that m ista k en b eg in n in g , with
the primary' goal o f co n sisten cy ra th e r th a n accuracy. A c co m p a n y in g
the unified sc h em a is a feeling o f c o n s o n a n c e — that all is right and
logical in the world ev en if their u n h a p p in e ss persists. T hat c o n s o ­
nance, however, is like a jigsaw puzzle— disturb o n e ele m e n t in the
pattern and th e pieces n o lon g er fit together. T he pattern b e c o m e s
incoherent, a n d th e earlier feeling o f c o n s o n a n c e is replaced b y a feel­
ing o f dissonance.
Clients attem p t to m ain tain c o n s o n a n c e even th o u g h th e sch em a
itself causes em o tio n a l distress, b e c a u s e d is so n a n c e is ev en m ore stress­
ful to them , and could result in a n a n x ie ty attack. T h e effect is ta n ta­
m o u n t to saying, "It's all right to b e unhappy, if th e reality is th a t this
is y o u r o n ly alternative in life." Even th o u g h it depresses th em , clients
will h o ld to th e p erception that th ey are sick b e c a u s e th eir b e h a v io r
and attitudes are b ased o n that p e rcep tio n ; th ey will defend th eir
"sick" a ssessm en t despite o v erw h elm in g co n tra d icto ry ev id en ce. T h e
key here is that th eir "reality" is a fabrication , a p ro d u ct o f clients' m is­
taken beliefs a b o u t them selves a n d th e world a ro u n d them.
O n e m e th o d o f c h an g in g th e m istak en reality th a t form s th e b a ck ­
grou nd for clients' u n h ap p in e ss is to attem p t to sh ow th em th e in c o n ­
sistency in their thinking. T he m e th o d b y w h ich this is d o n e includes
p ointin g o u t that their feeling o f c o n s o n a n c e is an illusion, that their
patterns o f th inking are full o f contrad ictions, an d th at th eir th o u g h ts
can 't possibly b e true. A lth ou gh clients will argu e against su ch a c o n ­
frontation, the therapist's p ersistence will create m o r e and m o r e dis­
s o n a n c e in their m istaken cogn itiv e system.
O n c e this d isso n an ce rea ch es a certain point, th e w h o le sc h e m a will
b e th ro w n into disarray, and clients will b e co m p e lled to a d ju st it to
gain a new feeling o f c o n s o n a n c e b ased u p o n their n ew percep tion. It
is essential that th e fo rm atio n o f a m o re ra tion al sy n th esis b e carefully
Countering Techniques: Hard
/

m a n a g ed . R e m e m b e r th at th e client's prim ary goal is consistency: It is

ju st as easy to adop t a consistent pattern th a t is o n ly h a lf as erron eou s
as their original pattern as it is to adopt a totally correct pattern. The
b u r d e n is u p o n the therapist to insu re that the c o n s o n a n c e -d is s o -
n a n c e -c o n s o n a n c e transition con clu d es with the m ost functional real­
ity p ossib le for th e client.

M eth o d
1. Ask y o u r clients to present their sc h e m a a b o u t them selves and their
view o f the world. They can h av e a specific sch em a or a general
one. W h ile th e clients are discussing th eir views, th e therapist takes
very careful n o tes record in g th e principles, evidence, a n d support
th e clients give.
2. Ask a series o f carefully prepared q u estio n s a im e d at challenging the
client's prepared schem es. Instead o f asking q u estio n s leading to
co u n te ra rg u m en ts, prepare p rob es in ten d ed to th row the client into
dissonance.
3. T he client will usually defend th e sch em a by giving excuses and by
co m in g u p w ith new rationales. You m u st co n tin u e to ask questions
that create d o u b t a b o u t th e client's form ulations. In all cases, m ain­
tain the client's d issonance until the client resynthesizes the schema.
It is im portan t th at you don't answ er the probes for the client.
4. As th e client m ov es to e m b r a c e a new, unified sch em a, m on itor
carefully to in su re that this new p ercep tion does not en com p ass the
seeds o f fu ture un happiness.

E x a m p le 1
SCH EM A: I m u st co n stan tly guard against ca tch in g germs.
PRO BE TO CREATE DISSONANCE: How d o you keep from b re a th ­
ing th em ?

SCHExVlA: If I don 't en g a g e in this ritual (cou nting m y steps w h en 1

w alk to m y car), I will get into a c a r wreck.
PRO BE: M a y b e you are using th e w ron g ritual. Perhaps th e correct
ritual is not to count. How w ould you know ? How m a n y acci­
d en ts w ere you in b e fo re you b eg an this ritual?

SCH EM A: It is terrible w h en o th ers reject me.

PROBE: W h e n you reject others, is it terrible for them ?
112 T h e N e w H a n d b o o k oi C o g n i t i v e T h e r a p y T e c h n i q u e s

SCH EM A: O th er p e o p le are cau sin g all m y problem s.

PROBE: How are you g o in g to stop o th ers from d o in g this?

SCH EM A: T he o n ly w ay I can b e h ap p y is by takin g care o f ev ery­

b o d y w h o needs it.
PROBE: W h e re will y ou get th e p ow er to tak e ca re o f ev e ry b o d y ?

SCH EM A: M y parents' values are correct. I m u st follow them .

PROBE: Are y o u r parents' valu es b etter than o th e r parents' values?
Are they the s a m e as o th e r parents' valu es? If th e y aren't, a re all
o th e r parents incorrect? H ow d o y o u k n o w w h ich parental values
are correct?

SCHEMA: If you are assertive, p e o p le will hate you.

PROBE: Do th ey love y ou n ow w h en you are passive?

SCHEMA: T h e o n ly way to b e h ap p y in life is to b e to u g h a n d hard,

and not to let p eople ta k e a d v an ta g e o f you.
PROBE: If you act that way, w h y w ould a n y b o d y w an t to love you ?

SCHEMA: W o m e n keep pressuring m e for a deep c o m m itm e n t.

T hey w o n 't grant m e m y in d ep en d en ce. T h ey keep g etting angry
with me.
PROBE: If y ou w ere a w o m a n , w ould you d ate yourself?

E x a m p le 2 : The Story o f Carol

We can fu rth er illustrate creating d isso n a n ce w ith th e story' o f Carol,
a m id d le-aged fem ale client. S h e was referred to m e b y h e r m ed ical
d o cto r b ec a u se sh e had a p h o b ia a b o u t g etting cancer. G en erally
speaking, this is not an a b n o r m a l fear, b u t in h e r c a se it was. R a th er
th a n w orrying, w h ich w ould have b e e n useful, sh e o b sessed o v e r it,
w h ich wasn't. Sh e con su lted d octors rep eatedly and b e c a m e terrified
if sh e fou n d a pim ple; sh e sp en t h ou rs e a c h w eek e x a m in in g herself.
Carol k n e w th e b est specialists an d received ex p ert ex a m in atio n s.
T h ese practitioners all found the s a m e thing— noth in g. T hey reassured
h e r a b o u t every' m o le and pain a n d told h e r th ey w e re certain th a t sh e
h a d a b so lu tely n o th in g to w orry ab ou t. But ev ery tim e th e y added the
h ab itu a l "O f cou rse w e will keep an eye o n it," Carol felt shattered. She
Countering Techniques: Hard
/

ign o red th e " n o th in g to w o rry ab o u t" and "we are certain" phrases and
focu sed instead o n th e h in t o f future problem s. Sh e left the doctors'
offices m o re upset th an before, co n v in ced that they w ere b e in g kind
to h e r and th a t th e y w eren 't telling her th e truth.
Carol c a m e to a few sessions o f therapy, and alth ou g h it helped her
in o th e r ways, it d id n ’t significantly red uce her phobia. Sh e had a
c o u n te r to every o n e o f m y argu m ents. If I asked, "W h y are you diag­
n o sin g y o u rse lf w h en all th e experts say you are clear?" Carol w ould
answer, "I kn ow h ow m a n y tim es d octors tell th e patient they are cer­
tain, ev en th o u g h th ey h av e severe doubts." I w ould say, "Look at how
m u c h y o u r w o rry in g costs you. You don 't red uce y o u r ch ances of get­
tin g c a n c e r b y o n e iota. All you d o is m a k e y o u rse lf m iserable by ago­
nizing." S h e w o u ld reply, "You m u st catch ca n ce r at its very earliest
stages. If you don't, you c o u ld b e o u t o f luck." If I said, "You have b een
search in g fo r years a n d c o m p e te n t physicians have n ev er found a n y ­
thing." Carol w ould respond. "But th e re is always a c h a n c e I will!
And so it con tin u ed . S h e sa b o ta g e d ev er)' c o u n te r her doctors and
I could th in k of. O n e day, after sh e had b e e n raging a b o u t the horrors
o f d y in g o f cancer, h ow unfair it w ould b e if sh e got it, a n d how the
m edical profession was in c o m p e te n t b e c a u s e th ey h ad n 't found it, I
b e c a m e frustrated a n d inadvertently created d isson an ce b y saying,
"Big deal. So you get ca n ce r and die. W hat's so G od awful terrible
a b o u t dying an yw ay? No m a tter w hat you do, n o m atter h ow much
you try to protect yourself, no m atter h ow hard you lo o k for signs, go
to doctors, and get ex a m in e d , it's all goin g to fail anyway. Because
s o o n e r or later, n o m atter w h a t you do, you are goin g to die— m a y b e
not o f ca n ce r b u t o f som eth in g, for sure. W hat's so terrible a b o u t that?
Do you th in k th e u niverse will stop w h e n you die? I don't m ean this
insultingly, b u t w h a t m ak es you so precious? Do you th in k th a t God
is c o u n tin g o n y o u r help? Do y ou th in k th at th e universe can't get
a lo n g w ith o u t you?"
Carol felt I w as u n sym p ath etic, b u t I had m ad e m y point; sh e b eg an
to th in k a b o u t m y q u estio n s and h e r fears. For a tim e sh e th ou g h t that
it w asn't d ea th sh e w as afraid o f b u t the pain o f dying. Sh e conclu d ed
th at th a t did n't w ash w h en sh e realized th a t sh e could die suddenly
a n d w ith o u t suffering. S h e realized that ev en if th e worst h ap p en ed
and it to o k h e r several m o n th s to die, h e r total pain for those m o n th s
w ould n o t add u p to a fraction o f th e pain sh e was creating for her­
s e lf b y w o rry in g a n d an ticip ating it for forty years.
114 T h e N e w H a n d b o o k o f C ognitive T h e r a p y T e c h n i q u e s

So w h y was Carol so a fraid o f death?

Later w e learned th a t m y d is s o n a n c e -c r e a tin g q u e stio n a b o u t
w h e th e r the u niverse co u ld n 't get alon g w ith o u t h e r was h e r co re
belief. R ather th a n b e in g afraid o f th e act o f dying, s h e was afraid o f
n ot existing. T he idea that s h e w ould s o m e d a y cea se to b e w as in tol­
erab le to her; sh e did n o t b e lie v e in a hereafter, so h e r p re sen t life was
all sh e had. Sh e feared th a t after h e r d eath o n ly a few p e o p le w ould
m o u rn her. H er fam ily m ig h t shed so m e tears, a n d th e fu neral m ight
b e full o f p ro m in en t p eople w h o w ould c o m e to grieve, b u t that
w ould b e it. In a sh o rt tim e few p e o p le w'ould th in k o f her. S h e w ould
b e c o m e a fad in g picture in a fam ily a lb u m th at few c o u ld identify.
After 150 years n o b o d y would r e m e m b e r her at all. E v ery b o d y w h o
knew h e r w ould b e long dead and it w ould b e as i f s h e had n ev er
existed at all.
This was Carol's fear, and in a strange, p arad oxical w ay it gav e h er
life th e m e a n in g a n d p u rp o se sh e was so afraid o f it lacking. As long
as sh e existed sh e could still, "Rage, rage against the dying o f th e light."
G iving up her fear w ould b e like su rren d erin g to oblivion.
T here are m a n y clients like Carol w h o can accept th e pain o f death
b u t not th e sh a m e o f it— th e s h a m e o f m eaninglessness.
T h ey ask me, "W hat's th e point? W h y g o th ro u g h all the pain and
suffering o f living w h en there is n o pu rpose? Death m a k es life n o n ­
sensical. W ith death ev eryth in g a person does in life b e c o m e s insignif­
icant, trivial, puny, not w orth a rap." Looked at in this way, life can
a p p e a r m eaningless. T he h u m a n race is three m illio n y e ars old, and
th e billions o f p eople w h o lived o n this p lanet b e fo re us s e e m gone,
forgotten. T he principle hold s true th at w h e th e r lo o k in g at earth's
in h a b ita n ts o f o n e m illio n years ago or o n e th o u sa n d years ago,
n a m e s and a c co m p lish m e n ts se e m to disappear. C ou n tries and
em pires are gone, as are m u c h o f art, architecture, and philosophy. A
handful o f n am e s has end ured, yet w e h av e no real im p ressio n o f the
p eople b e h in d the nam es, o f w h o th ey w ere o r w hat th ey did. M o st o f
the past is w rapped up in fables and fantasy.
As for th e c o m m o n p e o p le w h o preceded us, n o m atter h o w rich,
how successful, wise, beautiful, creative, or stro n g th ey were, their
births, struggles, and deaths are all g o n e an d forgotten.
This was Carol's original dilem m a: the idea that life ap p e a red p o in t­
less, w ith o u t significance or purpose. O n c e w e had identified the
p roblem , w e w e re ab le to w o rk tow ard co n so n a n c e . T h ro u g h c o u n s e l­
Countering Techniques: Hard 115.
/

ing, Carol c a m e to th e co n clu sio n th at life is n e ith e r hopeless nor

m e a n in g less— th at hid d en inside th e apparent ob livion o f all the peo­
ple w h o c a m e b efo re is a p u rp o se that sh e could n't see b y tryin g to
lo o k at o n e individual's life. Carol found that b y stepping back and
v iew in g the h u m a n species as an entirety a n d across time, sh e could
see th at the hum an race is progressing, advancing, and m o v in g forward,
an d th at all p e o p le are part o f th e progression. Sh e saw grow th and
a d v a n c e m e n t against ignorance, superstition, disease, poverty, and
injustice.
Carol was finally ab le to see that she could c o n trib u te b y trying to
m a k e th in gs ju st a little bit better. S h e c a m e to view h erself as part o f
th e h u m a n tide m o v in g forw ard an d to b eliev e that no life was m e a n ­
ingless, includ ing h e r own.

C om m en t
C lients will defend th eir m istaken realities against all attacks, even
if th e se realities are a fu n d a m en tal sou rce o f m isery for them . So m e
c an even tak e a certain pride in their u n iq u e constructions, and feel
that a b a n d o n in g th eir p h ilo so p h y w ould b e a sign o f w eakness or,
ironically, a sh ow o f irrationality. For th e m ore a d am an t victim s o f this
disorder, p arad oxical cou n selin g tech n iq u es m ight b e m o re helpful.
D isso n a n ce is painful, and th e use o f this te c h n iq u e is a classic e x a m ­
ple o f h a v in g to "hurt" th e client to help th e client. Fortunately, the
v ery n atu re o f th e d isord er ensures that th e hurt will b e brief, for the
m o m e n t th e fo u n d atio n s o f th e m istaken reality b eg in to crum ble,
clients m ov e q u ick ly to replace them . T h e therapist need o n ly m ake
sure th a t its rep la cem en t is as erro r-free as possible.
S o m e clients d o n 't need the help o f th e therapist to resolve their
d isson ance. T h ey can often resolve it them selves b y reassessing their
o w n valu es a n d desires.

F u rther In fo r m a tio n
C ognitive d isso n an ce th eo ry has b e e n ex am in e d in a large n u m b e r
o f pu b lication s (see A ronson, 1980; Festinger, 1957, 1964, for th e origi­
nal work). VVicklund a n d B rehm (1976) provide an early sum m ary, and
S c h a c h ter and G azzaniga (1989) have a recen t review o f m u c h o f Fes-
tinger's theory. Schauss, Chase, an d Hawkins (1997) provide a b e h a v ­
ioral an alytic in terpretation o f dissonance.
116.______ __ ___ __________ ________Tut New Handbook of CaGNiiiviJjiEfiAQi I eomques

C o g n it iv e F lo o d in g

Principles

A n o th e r form o f hard c o u n te rin g is flooding. It places clients in the

p resen ce o f a very aversive con d ition ed stim u lu s (CS) a n d d o e s n ot
allow th e m to escape. If th ey stay in th e setting long e n o u g h , th e e m o ­
tional con d ition ed resp o n se (CR) is often lessened o r rem oved . There
h av e b e e n m a n y ex p la n a tio n s for this effect. O n e view is that fatigue
gets paired with the CS, thus c o u n te rco n d itio n in g it. A n o th e r is that
extin ction elim in ates th e CS b e c a u s e th e u n co n d itio n e d stim u lu s
(UCS) never occurs. A third view is th a t reactive in h ib itio n sets in.
A cognitive ex p la n a tio n o f flo o d in g suggests s o m e th in g different.
Floo d in g can b e u n d ersto o d in term s o f rem o v in g a c o n d itio n e d
a void an ce response. A voidance is a m a jo r c o m p o n e n t o f a n y fear or
anxiety. O n c e clients feel the em otio n , they will d esp erately lo o k fo r a
w ay to run from p oten tially p ro b le m a tic situations, ev en if it is not
clear w h a t th ey are ru n n in g from.
A lthough escaping m akes them feel safer and leads them to believe
they h av e d em on strated so m e m e a su re o f co n tro l o v e r the event, their
ru n n in g away actually increases their fear, sin ce th ey don 't stick arou n d
lon g en o u g h to prove o r disprove th e validity o f th eir fears. There are
two possible c o n seq u e n ce s fo r clients placed in situations from w h ich
th ey ca n n o t escape: either th e d am ag e will o c c u r o r it will not. O n ly by
staying in th e situation will they find out. Therefore, the solu tion to
overcom in g catastrop hic fears is to im m erse o n e s e lf in the d a n g er and
see if th e catastrop he happens. It is the ultim ate experim ent.
It is im p o rta n t that clients b e p rohibited from escap in g if th e e x p e r­
im e n t is to work. If clients are perm itted to escap e b e fo r e th e ex p e ri­
m e n t is com pleted, th ey will c o n clu d e th a t it w as th eir esca p e that
saved them . If th ey are allow ed drugs, a drink, a co u n selo r's so o th in g
words, o r a n y o th e r su p p ort o r c o p -o u t, th ey will d e te r m in e th at it
was this variable th at kept th e ca ta stro p h e from h ap p en in g. W ith o u t
the proper controls, th e client will n e v e r b e a b le to see th a t their
beliefs w ere irrational in th e first place, a n d th e lik e lih o o d th at th ey
will attem pt to escap e again will b e increased.
A variety o f flo o d in g ap p ro ach e s are su m m a riz e d below.

M eth o d 1. I m a g e F loo d in g
1. H ave you r clients im agine, in vivid detail, th e feared sc e n e and
a cco m p an y in g irrational 'thoughts.
Countering Techniques: Hard 112
/

2. C o n tin u e until th e CR naturally subsides.

3. W h e n clients h av e irration al fears, instru ct th e m to feel the em otio n
until they get tired o f d o in g so.
4. Clients sh ou ld m ak e them selv es afraid at various tim es du ring the
day b y im ag in in g th e s a m e scen e with th e sam e thou ghts again and
again.
5. T h e therap ist m a y find it helpful to use h yp n osis in a flo o d -r e la x -
flo o d -r e la x sequ ence.

M eth o d 2. Verbal F loodin g

Have y o u r clients discuss, in great detail, all o f their past traum a
exp eriences. G o th ro u g h every incident m a n y tim es until y o u r clients
are tired o f talking a b o u t them.

M ethod 3. Focused Flooding

This is th e s a m e as th e o th e r m e th o d s, ex c e p t th at clien ts focu s on
CRs exclusively. C lients try' to recreate all o f th e p h y sical sen sation s
c o n n e c te d w ith th e a n x ie ty — rapid h eartb ea t, q u e a s y sto m a ch , dis­
o rie n ta tio n , a n d difficulty in b reath in g . T h ey c o n tin u e until the
sy m p to m s n a tu ra lly d eclin e. Fear is e x p e rie n c e d as d e lib era tely as
possible.
At least th ree h a lf-h o u r sessions are usually necessary for this tech­
nique.

M eth o d 4. N egative Practice

Have y o u r clients say all their irrational thou gh ts repeatedly until
th ey feel tired, bored, and annoyed. Stop th e practice only w h en they
a b so lu tely refuse to th in k a b o u t th em anym ore.

M eth o d 5. H ierarchy
1. Help y o u r clients m a k e a hierarch y o f their m o st-fea re d situations
a n d m o s t-fe a re d associated thoughts.
2. Im a g in e the least u psetting item o n th e list vividly with full e m o ­
tional effects. C o n tin u e until the client has n o CR w hile picturing
th e situation.
3. M o v e to th e next item o n th e hierarchy and repeat the process.
118 T h e N e w H a n d b o o k oi - C o g n i t i v e T h e r a p y T e c h n i q u e s

Exam ple: The Story o f Justin

A m od ified form o f flo o d in g was used successfully w ith a n o th e r
client afraid o f b e in g insane. Justin was a psychological h y p o c h o n ­
driac. He was v ery k n o w led g eab le a b o u t certain asp ects o f psy­
chopathology, and had read D5M-II. Each tim e h e g o t u p set h e w ould
lo o k in the b o o k and pick out th e psychological p ro b lem h e was h a v ­
ing that day. O v e r a 1 0 -y e a r period h e had diagnosed h im s e lf as
m anic, psychotically depressed, sociopathic, o b sessive com pu lsive,
an o rex ic and b u lim ic (w h e n e v e r h e lost o r gain ed a few pounds), and
an explosive p erso n a lity (w hen h e was angry).
He traced th e origins o f his a n x ie ty to his c o lleg e years, w h en h e
had taken so m e m ariju an a for the first tim e after b e in g g o ad ed in to it
b y an a cq u ain tan ce. T h e drug had b e e n laced with a h a llu cin o g en ic,
and w h en h e b e g a n to hallucinate, h e panicked. He stayed aw ak e for
24 hours, m o v in g b a ck and forth, in an d o u t o f panics. T he n ex t day,
w h en the a c q u a in ta n c e told him that th e m a riju a n a h a d b e e n laced,
his p an ic im m ed iately subsided. He th o u g h t th e drug cau sed th e fear
and didn't w o rry a b o u t it after that.
A b o u t a year later, Ju stin was sitting in a b e g in n in g p sy ch olog}'
class listening to a lectu re on th e psychological effects o f drugs. The
instru ctor said that th o se w h o h av e p an ic reaction s w h ile takin g m a r­
iju a n a are p ro b a b ly prepsychotic, o r at th e least h a v e b o r d e r lin e per­
sonalities. That night h e b e g a n to get scared, and b y m o r n in g h e had
a fu ll-b lo w n p a n ic attack. His panics stayed w ith h im o n an d o ff for
10 years. He had periods w h en h e felt n o anxiety, b u t w h e n e v e r h e
read or saw' so m eth in g that rem inded him o f in sa n ity th e fear w ould
resurface. He cou ld n I w atch TV sh ow s a b o u t p e o p le havin g n erv ou s
breakd ow ns; h e was terrified w h en h e w atch ed th e m o v ie One Flew Over
the C iukoos l\esl. He cou ld n 't stand read in g scien ce fiction a b o u t strange
p eople o n strange planets, b ec a u se h e would start to th in k h im s e lf
strange as well.
His co re b e lie f was easy to identify— h e knew it him self: "I a m close
to b ein g insane. At a n y m om en t, stress could m a k e m e flip o v e r and
b e c o m e p e rm a n en tly psychotic." W e can c o n sid e r his b e lie f as a c o n ­
ditioned stim u lu s as sh o w n on th e n ex t page.

Note: In classical c o n d itio n in g th e c o n tig u ity (the close asso ­

ciation o f CS and UCS in time) is co n sid e red im p o rtant. In cog­
nitive con d itionin g , the c o n tin g e n c y (the m e n ta l c o n n e c tio n o f
o n e ev en t w ith another, n o m atter w h at th e tim e fram e) is all that
Countering Techniques; Hard
/

is necessary. In th e a b o v e e x a m p le co n tin g en cy was present but

co n tig u ity was not. See Schw artz (1978) and Rescorla (1967) ab o u t
th e distinction.

UCS
(u n ex p la in e d h allu cin ation w h ile o n drugs)

CR
(anxiety)

CS
(association a y e a r later that he m ay b e prepsychotic)

Ju stin h a d g o n e to m a n y co u n selo rs and had tried m a n y tech n iqu es

to n o avail. Finally, w e decided to use flooding. He was instructed to
ta k e o ff th re e m o rn in g s o v e r th ree successive weeks. He was to allow
at least five h ou rs for th e techniqu e.
Each tim e h e was told to lie in his b ed w ith o n ly a dim light sh in ­
ing in from th e n e x t room . He had to lie th ere for five hours, with all
distractions rem oved. He could accept no p h o n e calls, th e radio and
TV had to b e turn ed off, h e could n't get up a n d w alk around, read a
b o o k , or distract h im self in a n y way. His entire focu s and en v iro n m en t
w as to b e m ental.
Justin was told not to fight the fear o f g o in g crazy and not to avoid
it in a n y w ay during his flo o d in g time. Instead, h e was to con cen trate
o n th e idea o f g o in g insane, feel th e a n x ie ty intensely, and m ain tain
th e fear fo r as lo n g as h e was a b le du ring th e fiv e -h o u r period. W h e n ­
ev er h e cau g h t h im s e lf getting tired, h e was to red ou b le his efforts and
co n tin u e to th in k a b o u t g o in g crazy. He was to keep the th o u g h t at a
m a x im u m level. After each session w e set an a p p o in tm en t for him to
discuss his exp erience.
His first session was difficult. For the first three h ou rs h e panicked—
not continually, but in waves. He said that h e m ust have had at least
eight p a n ic attacks. W h e n h e felt the fear, h e desperately w an ted to
ru n o u t o f th e b e d ro o m . T h e o n ly thing th a t kept h im in the b ed was
this thou ght:

I h av e b e e n scared for 10 years; m y life is g o in g now here. I

h a v e lost m y m ost im p o rta n t relation sh ips and h av e not grow n
120 T h e N e w H a n d r q q k .q e .C o g n i t i v e T h e r a p y T e c h n i q u e s

in m y career, all b e c a u s e o f this fear o f g o in g insane. If this fear

is true, I will g o insane. But w h a t o f it? It w ould h a p p e n s o o n e r
or later anyway, w h y n o t tod ay ? Today is as g o o d a d ay as a n y
o th e r to b e c o m e psychotic. If it is not g o in g to h a p p en , well, let
m e find that o u t now.

For the first three hours h e feared insanity, b u t for the next two h e had
trouble keeping his mind on the fear. His mind started to wander; he
b eg a n to think o f w hat h e was going to have for dinner, w here h e was
going to go o n his vacation, a new car he needed to b u y Near th e en d o f
the five hours he was glad to stop. The w h ole exercise was boring him.
Justin's n e x t tw o sessions w e re easier. He had tr o u b le th in k in g the
b e lie f and o n ly h a d tw o or three waves o f panic. He g o t b o r e d m o re
qu ickly and h e felt little a n x iety a b o u t insanity. In the final session, th e
thou ght didn't b o t h e r h im at all. He sp en t m o st o f the session th in k ­
ing o f o th e r things. He could n't force h im s e lf to th in k a b o u t it b e c a u s e
it seem ed silly.
Flooding didn't c u re Justin as qu ickly or as easily as this a c c o u n t
suggests. It to o k him several m o n th s o f practice at o v e rco m in g o c c a ­
sion al p a n ic attacks b e fo re th e p ro b le m was solved. As Justin
d escribed it later,

T he fear w asn't the s a m e an y m o re. T he ed ge seem ed to h av e

b e e n taken o ff o f it. Sin ce th e flood ing, I k n e w th e fear was ju st
bullshit. I knew th e th ou g h t was ju st a silly superstition. It to o k
m e a w h ile to b e sure, I h ad to keep o n testing myself, b u t s o m e ­
w h ere inside I knew.

My last rep ort from Justin, m a n y years later, was v ery positive. He
w ould occa sio n a lly get so m e mild fear a b o u t insanity, a b o u t ev ery
year or so, b e c a u s e h e let his th in k in g get lazy. But h e rep orted that
h e could easily get rid o f it with a little cogn itiv e work.

C om m en t
T h e key to all flo o d in g tech n iq u es is for clients to r e m a in in th e
feared scen e until their b o d ie s n a tu rally red u ce th e CRs. If th ey escap e
w ithou t co m p letin g th e flood ing, th e fear increases.
Floo d ing is o n e o f th e last te c h n iq u e s used in th e co g n itiv e restruc­
turing rep ertoire b eca u se th e te c h n iq u e is q u ite painful.
O f course, for flo o d in g to b e appropriate, therapists m u st b e certain
that no real U CS can o c c u r in the flo o d in g proced ure. It is c o m m o n
sen se not to flo o d sch iz o p h re n ic clients w h o are afraid o f h a llu cin a t­
ing o r depressive patients w h o are afraid o f c o m m ittin g suicide.
Countering Techniques: Hard 121
/

Further In fo rm a tio n
Flo o d in g and im p losiv e therapy, a lth ou g h primarily beh avio ral
rath er t h a n cogn itiv e tech n iqu es, may b e b a sed on rem ov in g a c o n d i­
tioned a v o id a n ce response. T he most c o m p reh en siv e w ork o n the
su b je c t is B o u d ew y n s and Sh ipley (1983). Also see Stam pfl and Levis
(1967) for im plosive therapy.
Related te c h n iq u e s are negative practice, m assed practice, im plo­
sion, a n d reactive inhibition.
W o lp e (1958, 1969, 1973) discusses im a g e flood ing a n d its variations.
T he m ost c o m p re h e n siv e review is in M arshall, Gauthier, and G ordon
(1979). D u n lap (1952) first discussed negative practice.
External, reactive, a n d con d ition ed inhibitions have b e e n offered as
n o n c o g n itiv e ex p la n a tio n s for flooding. See Rescorla (1969) and Z im -
m e r-H a rt and Rescorla (1974). Also see Clark Hull's (1943) theoretical
discussion o f sEr and Ir, and Rescorla (1967) and Schw artz (1978) for
m o re th eoretica l exam in ation .

C o g n it iv e A v e r s iv e Co n d it io n in g

Principles
Aversive c o n d itio n in g is a form o f hard co u n te rin g in w h ich die
therapist teach es clients to p u nish th eir ow n irrational beliefs. T he th e ­
ory is that if aversive stim uli are paired with false beliefs, clients will
b e less likely to th in k th em , and th e th ou g h ts will b e less likely to
elicit c o n d itio n e d responses. This is th e opp osite o f reinforcing a
rational belief— instead o f eating a ca n d y b a r for th in k in g a rational
thou ght, th e clien t m ight b e en co u ra g ed to take a dose o f castor oil for
th in k in g a negative thought.
M a n y stim uli can n eg atively sensitize irrational thou ghts; these
includ e n eg ativ e beliefs, images, em o tio n s; un pleasan t physical sensa­
tions (like shock), nausea, m u scle strain; and u n p le a sa n t behaviors. If
th e re are e n o u g h pairings, and if th e stim uli are aversive enough, the
th ou g h ts th em selv es will b e ex p erien ced as unpleasant.

M eth o d 1. Self-P un islim ent

1. U se th e client's m aster list o f beliefs.
2. Record the m a jo r typ es o f situ atio ns in w h ich th e client is likely to
h av e th ese thoughts. Each situ atio n sh ou ld b e d escribed with a spe­
cific scen e and in e n o u g h detail so that the client can clearly visu­
alize it.
122 T h e N e w H a n d b o o k o f C o g n it iv e T h e b a k T ec h n iq u e s

3. Have th e client im a g in e o n e o f th e scen e s w ith its a c c o m p a n y in g

irrational thou gh t; w h e n it is clearly in m in d give h im o r h e r the
follow ing instructions.

Okay. Now I w ould like you to im a g in e th e w orst p ossib le

c o n se q u e n ce s o f th inking this irrational thou ght. W h a t bad
things h av e o ccu rred b e c a u s e you h av e th o u g h t this way?
W h a t pain has this th ou g h t giv en you ? W h at g o o d things
have b e e n rem oved o r n e v e r h a p p e n e d ? W h a t has it d o n e to
y o u r se lf-e steem ? W h a t has it d o n e to y o u r relation sh ips?
How has it h u rt y o u r life? I would like y ou to im a g in e all th ese
things h a p p e n in g sim p ly b e c a u s e o f y o u r irrational thought.
D on't ju st think a b o u t th e b ad things, b u t picture th em until
th ey are clearly in y o u r mind, so th at you can feel th e n eg a ­
tive em otions.

4. Repeat th e aversive sc e n e at least th re e tim es with e a c h irrational

thought. If you wish, h a v e y o u r client say o u t loud w h a t h e o r she
is im ag ining so th a t you can help to m a k e the scenes as aversive as
possible.
5. A u d iotap e th e exercise and instruct the client to listen to th e tape
th re e tim es a w eek for several weeks.

M eth o d 2. S ta n d a r d A versive I m a g e s
1. Stand ard im ages o f vom iting, a sn a k e pit, spiders, o r b e in g despised
b y ev ery o n e can b e used. Interw eave th e im ages with the irration al
th ou g h ts so that the tw o b e c o m e closely associated. For exam p le,
o n e client had low se lf-e ste e m a n d was fre q u e n tly depressed
b eca u se sh e was d ep en d en t on others. S h e m a n ip u la ted o th ers so
th at th ey w ould m a n a g e h e r finances, plan h e r vacations, a n d direct
h e r life. W e used th e following aversive script.

Im ag in e that you are h aving m a n y p ro b lem s in y o u r life

that need to b e corrected. Your c a r is b ro k en , y o u r sin k is
d o g g e d up, you haven't g o tten a pay raise in th re e years, and
you 're overdraw n at y o u r b an k. For th ree years you h av e g o n e
with a m a n w h o says h e is n ot read y to marry.
You start thinking: "S o m e b o d y needs to ta k e ca re o f me. I
need s o m e b o d y to solv e th ese problem s. I am to o fragile to
co p e with life." As y o u th in k th e se thou ghts, y o u b e g in to get
a q u ea sy feeling in you r stom ach . You feel na u seo u s. Sm all
Countering Techniques: Hard 123
/

ch u n k s o f fo o d c o m e to y o u r m o u th an d taste bitter. You sw al­

low th em back down.
You start th in k in g o f g etting s o m e o n e to help you, so m e o n e
w h o will call th e b a n k o r find a plumber. Hut the thought
m ak es you feel sicker. Your eyes water. S n o t and m u cou s from
y o u r n o s e are ru n n in g dow n into y o u r m outh. Your stom ach
is turning. You th in k ab o u t calling y o u r e x -h u s b a n d so that he
c an tak e care o f you, a n d ab o u t asking y o u r m o th e r to call
y o u r b o ss to com p lain a b o u t y o u r not getting a raise, but
th ese th o u g h ts cau se you to feel very' sick. You start to vomit.
You vom it all o v e r yourself. It starts dripping dow n y o u r legs
o n to th e floor. You th in k again o f h ow so m e b o d y m ust take
c a re o f you and y ou v o m it even more. There are yellow and
brow'n stains all over y o u r clothes.
You start havin g the dry heaves. You ca n 't stop retching. It
feels like y o u r insides are a b o u t to c o m e out.

2. T h e b est aversive images are th ose selected by clients, b ased on

th eir ow n idiosyncratic fears an d disgusts. Have clients describe the
m ost disgusting, detestab le ex p erien ces they have ev er imagined
h a p p e n in g to them . You can m a k e a b r ie f hierarchy. Then, using the
a b o v e in terw eav in g m ethod , tie th ese aversive im ages to their irra­
tio n al thoughts.

M eth o d 3. P hysical Aversion

Have th e client im ag in e th e irrational thought. W h e n it is clearly in
m ind , asso cia te with it an external aversive stim ulus such as a mild
finger electrical sh o c k or a sn ap o f a r u b b e r band. O th er op tion s are
ten sin g up th e sto m a ch m uscle, holding one's breath, n o x io u s smells
like su lfu r odor, o r strenu ou s, painful physical exercise. A th ou g h t and
an aversive sen sa tio n m u st b e paired repeatedly in order for the
th o u g h t to b e c o m e noxious.

M eth o d 4. R ed Taping
Red tap in g allow s clients to en g age in the negative thinking, but
on ly after th ey h a v e p erform ed a variety o f aversive activities. Pick a
b e lie f that clients are ob sessed with, su ch as: "I a m sick a n d inferior to
everyone." In stru ct them that they are perm itted to th in k this thou ght
o n ly after th ey h av e earn ed the right to d o so. To earn the right, they
124 T h e N e w H a n d b o o k o f C ognitive T h e r a p y T e c h n i q u e s

m u st d o th e following: exercise for 15 m in u tes, drin k th re e glasses o f

water, record the tim e an d p lace w h ere th ey will p erm it th em selv e s to
en g age in th eir obsession, and w rite out ev ery n o n o b se ssiv e th ou g h t
they h av e for at least 2 0 m inutes. O n ly after p e rfo rm in g th e se tasks are
th ey perm itted to ob sess for 10 m inutes. If th ey w an t a n o t h e r 10 m in ­
utes, th ey m u st d o the s a m e ro u tin e again. T he resp o n se cost b e c o m e s
so ex p e n siv e that after a w h ile m ost clients prefer to skip th e 10 m in ­
utes o f obsessing.

M eth o d 5. R em o v in g Positive S tim u li

A n o th er form o f aversive co n d itio n in g entails th e rem ov al o f s o m e ­
thing positive. The effect is sim ilar to associatin g a n egative stim ulus
to th e belief. T he rem ov ed positive variab le can b e o n e o f m a n y
things: need ed relaxation; a pleasant image, a positive em otio n , o r a
positive b elie f— a n y o r all m ig h t b e rem oved the m o m e n t y o u r client
su ccu m b s to the irrational belief. In th e literatu re this te c h n iq u e is
often called covert resp o n se cost or negative p u n ish m ent.
Like o th e r covert sensitization procedures, a large n u m b e r o f rep e­
titions is o ften needed. Clients practice with the therap ist as well as at
h o m e by listening to tapes o f the exercise.

M eth o d 6. N egative L a b e ls
W ords are sy m b o ls o f larger concepts, a n d th ese sy m b o ls often
have a n egative c o n n o ta tio n s th a t p ro d u c e av ersiv e e m o tio n a l
responses. By associatin g negative labels to th e clients' irrational
thoughts, therapists can help them d ev elo p a negative re s p o n se to the
thou ghts them selves.
W h e n e v e r clients th in k o r express th e irration al th ou ght, th ey
sh ou ld say th ese w ords to them selves: d u m b , lame, m u dd led, asinine,
b ird -b ra in ed , childish, inane, absurd, foolish, n on sen sical, ridiculous,
laughable, ludicrous, idiotic, m eaningless, preposterou s, h a lf-b a k ed ,
groundless, inept, vapid, boring, m o n o to n o u s , drivel, la m e -b ra in ,
b abb le, dense, oafish, gullible.
So m etim es you m ay ask the clients to iden tify th eir th o u g h t b y the
negative label, e.g., "I had m y idiotic th o u g h t yesterday, b u t I didn't
have th e la m e -b ra in one," or "I got upset again w h en I had th e m o n o t ­
o n o u s th o u g h t th at others are b etter th a n me." As in all aversive c o n ­
ditioning, it is essential th a t clients la b el th eir th o u g h ts, b u t n ot
them selves, as negative, e.g., '“I am smart, b u t this th o u g h t is idiotic"
Countering Techniques: Hard 125
/

C om m en t
W h e n e v e r therapists use aversive te c h n iq u e s to ch a n g e thoughts,
they ru n th e risk o f clients' attaching negative feelings to m o re than
ju st th e targeted variable. Clients can start feeling n egative a b o u t th er­
apy, th e therapist, th e co u n selin g tech n iqu e, o r them selves. It is essen ­
tial that th e therap ist provide exact d iscrim in ation training to keep the
aversive asso ciatio n s from generalizing to o th e r stimuli.
As in th e case o f positive reinforcers for positive thoughts, negative
pairing w ith n egative th ou g h ts m u st b e c o m m e n su ra te w ith the
o ffen d in g thought. Clients m u st not feel th a t they shou ld ch op o ff an
arm for a relatively m in o r transgression.
M o st aversive tech n iq u es are used in c o n ju n c tio n with escap e c o n ­
ditioning. S ee th e n ex t sectio n o f this chap ter for an explanation.

F u rther In fo r m a tio n
A great deal o f research has b e e n d o n e o n aversive conditioning.
A lth o u g h m ost o f it has not b e e n cognitively oriented, the read er can
easily m a k e th e necessary' adaptation. C ognitive aversive techniqu es
h a v e b e e n used successfully for the treatm en t o f obsessive thoughts
(H oogduin, de H aan, Schaap, & Arts, 1987), b u t m u c h o f th e research
show s m ixed results as to th e effectiveness o f the b e h a v io r procedures.
See particularly Barlow, Agras, Leitenberg, Callahan, and M o o re (1972),
Barlow, Leitenberg, and Agras (1969), Barlow, Reynolds, and Agras
(1973), Brownell, Hayes, and Barlow (1977), Cautela (1966, 1967, 1971a,
1971b), Hayes, Brownell, a n d Barlow (1978), Singer (1974), T h o rp e and
O lson (1997), O 'D o n o h u e (1997). S o m e au tho rs have suggested that
th e re are always proced ures su p erio r to aversive tech n iq u es (Lavigna,
1986).
Originally, I called this te c h n iq u e "self-p u n ish m en t" (Casey & Me
M ullin, 1976, 1985; M e M ullin & Casey, 1975).

C o g n it iv e E sca pe C o n d it io n in g

Principles

Escap e c o n d itio n in g is m ost often used in c o n ju n c tio n with aver­

sive tech n iqu es. A n y stim ulus that rem oves an aversive state b e c o m e s
a n eg ativ e reinforcer. If th e therapist has con d ition ed clients to feel
pain w h e n e v e r th ey th in k a particular irrational thought, th ey can
126 T h e N e w H a n d b o o k , or- C o g n i t i v e T h e r a p y T e c h n i q u e s

^ V

then b e tau g h t to escap e this pain b y th in k in g a ratio n a l thou gh t. T h e

rational th ou g h t w ould th erefore b e m o r e likely to occur, w h ile the
irrational th ou gh t w ould d ecrea se in frequency.
The full aversive-escape paradigm is often called covert sensitization,
and it can b e diagram m ed as follows. In th e exam ple, an anim al is c o n ­
ditioned to fear a red light b ecau se it has b e e n paired with shock. The
shock is rem oved if the anim al presses a lever that switches the light to
green. Thus the lever pressing and th e ap p ea ran ce o f th e green light are
negatively reinforced and are m ore likely to increase in frequency.
W hat is true for a b e h a v io r like lever pressing is also true for
thoughts. In the cogn itiv e e x a m p le th e rational th o u g h t allow s th e
client to escap e from th e pain elicited b y th e irrational th ou g h t. The
irrational th o u g h t (NS) b e c o m e s less likely to occur, w'hile the rational
th o u g h t (CS) increases in frequency. As a result, th e ra tio n al th o u g h t
is negatively reinforced.

Noncognitive

~ red light (NS) I

pain (CR) —

- shock (UCS)

green light (CS)

NS = neutral stimulus (removes CR)
UCS = unconditioned stimulus
CR = conditioned response
CS = conditioned stimulus

Cognitive
irrational thought (NS)

pain (CR)

aversive variable (UCS)

(physical, thought, image)

rational thought (CS)

(removes CR)
Countering Techniques: I lard 121
/

M eth o d 1. R e lie f f r o m Aversive State

C o n n e ct an aversive stim u lu s to a negative belief. You c a n use self­
p u n ish m e n t, aversive im ages, physical aversion, or negative labels.
(See previou s section o n cogn itiv e aversive conditioning.)
After the aversive state is created, have y o u r clients th in k the real­
istic, rational th ou g h t. W h e n it is clearly in mind, rem o v e the aversive
state im m ediately. If a finger sh o c k has b e e n used to create th e aver­
sive state, im m ed ia tely rem o v e it u p o n th e presentation o f th e rational
thou gh t. If a negative im ag e is presented, the im age is ch an ged to a
positive picture as s o o n as the rational th ou g h t occurs. For example,
in th e aversive c o n d itio n in g e x a m p le m e n tio n ed earlier (the vom iting
sc e n e in terw o v en w ith th e irrational thought, "S o m e b o d y needs to
ta k e care me," pp. 1 2 2 -1 2 3 ) th e follow ing esca p e scen e was presented.

You are still feeling ex trem ely nauseous. You are a b o u t to

v o m it again, b u t th en you start th in k in g ab o u t how you really
can take care o f yourself; you can solve you r p rob lem s on you r
own. You can fix th e car and th e sink, and you can correct the
o v erd raw p ro b le m at y o u r b a n k . You can c o n fr o n t y o u r
b o y frie n d and y o u r boss. Imm ediately, you start feeling better.
You take a d eep breath, and y o u r lungs and stom ach start clear­
ing. You w alk out o f you r h o u se a n d feel the fresh clean air. You
feel th e w arm sun. There is a g en tle breeze. You lie dow n o n soft,
m ossy grass, u n d e rn e a th a willow tree, relaxing as you c o n te m ­
plate y o u r streng th and h ow you can solve y o u r problem s by
yourself. You w alk b a ck into y o u r h ou se and o p e n all o f your
window s. You clean everything, scru b b in g floors, walls, rugs, and
furniture. You throw aw ay y o u r v o m it-sta in e d cloth es and put
o n new, fresh, crisp ones. You start th in k in g o f h ow you will h a n ­
dle all y o u r o th e r p ro b lem s yourself, just as you h andled these.
You m a k e a resolution that you w on't ask a n y o n e else to help
y o u w ith p ro b lem s th at you can solv e yourself. You feel confi­
den t an d self-assured.

M eth o d 2. Anxiety R e lie f

A n o th e r form o f es ca p e co n d itio n in g is called a n x iety relief. This
te c h n iq u e uses th e sa m e proced ures as th e p reviou s m eth od , except
that th e client seeks an escap e from a n x iety instead o f from o th er
types o f n o x io u s stimuli. In the escap e scen e th e client im agines the
128 T h l N e w H a n d b o o k oi - C o g n i t i v e T h e r a p y T e c h n i q u e s

tension rapidly su bsidin g as so o n as th e rational th o u g h t is believed.

C om m en t
The essential feature o f all escap e tech n iq u es is that th e aversive
state is rem oved o n ly w h en clients th in k th e realistic th ou g h t, th us
m ak in g th e th ou g h t a negative rein forcem ent. W h ic h e v e r e s c a p e te c h ­
niqu es are used, th e therapist sh o u ld record th e p ro c e d u re a n d urge
clients to listen to th e tap e at least th re e tim es a week. Clients feel a
great deal b e tte r a b o u t es ca p e c o n d itio n in g th a n th e y do a b o u t aver­
sive conditioning. T he asso ciation b o n d s are stronger, an d clients are
m o re m otivated to practice th e techniques.

F u rther In fo r m a tio n
Cautela has p ro b a b ly d o n e th e greatest a m o u n t o f w o rk o n im ag e
escap e c o n d itio n in g (see A scher & Cautela, 1974; Brownell, Hayes, &
Barlow, 1977; Cautela, 1966, 1967, 1971b; Hayes et al., 1978; Kazdin &
Sm ith, 1979). There are recent discu ssions a b o u t w h e th e r su ch c o n ­
cepts can b est b e exp lain ed b y b e h a v io ra l o r cogn itiv e theory. S ee
W ilson, Hayes, an d Gifford (1997) and refer to th e referen ces listed in
th e aversive an d a v o id an ce sections.

Co v ert A v o id a n c e

Principles

A voidance co n d itio n in g is sim ilar to escap e con d ition in g , ex cep t

th a t th e e m p h a sis is placed u p o n preven tin g th e aversive stim ulus
from occu rrin g rath er th a n first ex p e rie n cin g th e aversion stim ulus.
U nd er this techniqu e, a n y b e h a v io r that avoids an aversive e m o tio n is
reinforced, m ak in g that b e h a v io r likely to in crease in frequency. This
is as true for th ou g h ts as it is for b eh av io rs. Clients are likely to
strongly b e lie v e a n y th o u g h t th a t keeps a n x iety away. Classic e x a m ­
ples o f av o id a n ce th ou g h ts are:

I sh o u ld n t th in k a b o u t m y problem s.
I sh o u ld n 't ch an g e; c h a n g e is dangerous.
• It's m y parents' (spouse's, boss's, therapist's) fault.
• I am not resp on sib le for w h a t has h a p p e n e d to m y life.
Countering Techniques: Hard 129
0

Covert avoid an ce uses this sam e principle by havin g clients switch

their th ou ghts so that they can c o p e m ore successfully (As with all the
te c h n iq u e s discussed in this book, extrem es are to b e avoided. The goal
h ere is to avoid pain, not to teach clients how' to "cop out" o f their
responsibilities at ever)' opportunity.) T he rational b e lie f substitutes for
th e irrational on e ; if it works, the rational b elie f will b e c o m e stronger.
If th e client th in k s a rational th ou g h t w h ile im agining the b e g in ­
nings o f a negative scene, then the aversive stim ulus (w hether an
im ag e o f vom iting, shock, o r th e w orst possible co n seq u e n ce s) is
avoided. If th e clien t doesn't th in k th e rational thought, th en the aver­
sive stim u lu s is presented in full and c o n tin u e s until th e client finally
th in k s o f th e ra tion al belief. Clients quickly learn that rational think­
ing p o stp o n es or elim in ates p u nishm en t.

M eth od
1. M a k e a h iera rch y o f p rob lem situations and th eir a cco m p an y in g
irrational thoughts.
2. Pick th e low est item on the h ierarch y and have th e client im agine
th at situ ation a n d th e th ou g h ts associated w ith it. Pair th e thou gh ts
w ith a negative em o tio n , image, or external aversive stimulus.
Repeat several tim es until th e client pairs the negative feeling with
th e irrational thought. T he n egative em o tio n sh ou ld b e strong and
q u ite aversive.
3. Have th e client im ag in e th e sam e situations, but this tim e h av e him
su b stitu te a rational th ou gh t in place o f the irrational thou ght
im m ed iately b e fo re th e negative em o tio n occurs. If the rational
th o u g h t is strongly believed the aversive stim ulus is not presented;
if it is n o t b elieved th e n th e negative stim ulus occurs.
4. Keep alternatin g th e se co n d an d third steps, m o v in g up the hierar­
chy as y o u do, so th a t th e client learns that rational th in kin g will
h elp him or her to avoid negative con seq u en ces.

E x a m p le
A n u m b e r o f rational th ou g h ts can help clients avoid negative
em o tio n s. H ere are som e:

1. I can b e happ y ev en th ou gh ev eryth in g isn't g o in g perfectly.

2. I can e n jo y m y life ev en though I had a b ad childhood .
3. I can alw ays forgive m y se lf for past mistakes.
13 0 Tut N e w H a n d b o o k q e C ognitive T h e r a p y T echniques

4. Real d ang ers are alm ost alw ays extern al. No th o u g h t o r e m o tio n
can really hurt me.
5. I am not to b la m e for things I c a n n o t control.
6. 1 accept that th ere are tim es in m y life w h en 1 will get a n x io u s or
depressed, and I don 't h av e to push th e se e m o tio n s o u t o f m y life
forever to b e gen erally happy.
7. Em barrassin g m y se lf m a y b e am u sin g for m e as well as fo r o t h ­
ers. I can afford to laugh at myself.
8. M y life is not so im portant to h u m a n ity th at 1 h av e to live in
dread o f all possible m isfortunes that m a y befall me.
9. I am n o t in th e c e n te r o f e v e ry o n e else's universe. People are n ot
sp en d in g th eir lives co n ce n tra tin g o n h ow m a n y m istak es I
make.
10. T h e world was created b y nature, not b y me. It d o e sn 't h a v e to
follow m y rules o f fairness, justice, or equality.
11. It is not p ossib le for m e to b e b e tte r in ev ery th in g t h a n e v ery ­
b o d y else.
12. N o b o d y will care a b o u t m y petty m istakes after I a m gone.
13. Looking b a ck at m y life I can see that m o st o f th e things I w o r­
ried a b o u t in th e past proved to b e u n im p o r ta n t a n d insignifi­
cant.
14. T h e m ore I achieve, the m ore so m e p e o p le will resen t m e. I
sh ou ld r e m e m b e r M ark Twain's epigram , "Few o f us can stand
prosperity— a n o th e r m a n 's I mean."
15. T he progression o f the h u m a n species will not b e p e rm a n e n tly
im peded if I don 't reach m y p erson al search for glory. In fact,
m ost p e o p le w on't ev en notice. T h ey are to o bu sy w ith th eir ow n
searches.
16. Nature hasn't giv en m e th e p ow er to co n tro l ev e ry th in g a ro u n d
me. Besides, it's n ot a w h o le lot o f fun b e in g resp o n sib le for the
world.
17. I am not the o n ly o n e losing o u t o n the g o o d life. N o b o d y has it.
T h e g u y w h o ap p ears to h av e it— d o esn 't! It's ju st a n illusion
b ec a u se w e d o n t k n o w h im well e n o u g h . T h e m illion aire sits on
top o( a pile o f b ro k e n relationsh ips; th e m o v ie star loses the
freedom to w alk d ow n a p u blic street w ithou t b e in g attacked b y
the paparazzi. T h e single person is lonely; th e m arried p e rso n is
b ored. We all h av e o u r sh in in g m o m e n ts, th o se few fleeting
m o m e n ts w h en w e and th e w o rld a rou n d us seem to glitter (the
birth o f a child, m ak in g love to s o m e o n e w e love, w in n in g th e big
Countering Techniques; Hard 131

gam e, g etting th e degree, etc.), b u t such tim es are few and m ight­
ily short. T h e o n ly real profanity is w h e n w e pulverize th e se sh in ­
ing m o m e n ts with th o u g h ts su c h as, "It's not sh in y enough. Is this
all th ere is? It's not as m u c h as I was prom ised. Is it goin g to end
so o n ? I w o n d e r if I am h an d lin g the m o m e n t correctly. Others
h av e sh in ier moments."

C om m en t
W ith m ost o f o u r clients, av o id an ce co n d itio n in g occu rred naturally
after th ey had practiced a v e rsiv e -esca p e conditioning, w hen they
started to th in k the realistic th ou g h t earlier in th e con d itionin g
s e q u e n c e in ord er to avoid th e negative stimulus.

F u rth er In fo r m a tio n
The fu n d a m en ta l principles o f avoid an ce con d ition in g have b een
estab lished for m a n y years. S ee Seligm an an d Jo h n s o n (1973) for an
e m p h a sis o f th e cognitive c o m p o n e n ts. For noncognitive, see Azrin,
H u chinson, and Hake (1967), de Villiers (1974), Foree and Lo Lordo
(1975), Garcia and K oelling (1966), H errnstein (1969), H ineline and
R achlin (1969), K am in (1956), Kamin, Brimer, and Black (1963), M ow rer
and L am o rea u x (1946), R ichie (1951), Sidm an (1953, 1966), So lom on
(1964), S o lo m o n an d W y n n e (1954, 1956), Turner and So lo m o n (1962).
Recently, b e h a v io r analysts suggest th a t tea ch in g cognitive avoid­
a n c e m ay h av e negative effects on clients. Suppression m a y cause a
r e b o u n d effect (see Flayes, 1995; Hayes, Strosahl, & W ilson, 1996; Hayes
& W ilson , 1994; and Hayes, W ilson, Gifford, Follette, & Strosahl, 1996).
 V

FIVE

Countering Techniques: Soft

I n the previous chapter, w e discussed c o u n te r in g te c h n iq u e s th a t try

to increase clients' levels o f arousal. High e m o tio n a l c o u n te rin g can b e
effective for certain types o f beliefs, particularly w h en it pulls in the
client's an ger against irrational cognitions. An aggressive o r assertive
attack against a depressive o r passive th o u g h t helps clients c h a n g e not
o n ly their thoughts, b u t also th e em o tio n s that a c c o m p a n y them . But
there are tim es w h en soft em o tio n s are m o re help fu l in p arryin g
clients' beliefs. Soft em o tio n a l tech n iqu es, su c h as calm , relaxed c o u n ­
tering, can defu se high em o tio n a l arou sal and m a k e it easier for clients
to m ore g en tly c h a n g e their beliefs.
For a n x ie ty -p ro d u cin g beliefs, it is often far b e tte r to c o u n te r in a
m ore relaxed manner. It has b e e n theorized that soft c o u n te rin g
reduces th e client's state o f anxiety, w h ile aggressive c o u n te r in g
increases it. In a relaxed state the irrational b e lie f is ch a llen g ed b y
b o th the c o u n te r th o u g h t an d th e c o u n te r em o tio n , providing tw o
active treatm en t elem ents.
This ch a p ter describes h ow to teach clients to use soft e m o tio n s to
co u n te r th eir beliefs.

R e l a x e d Co u n t er in g

Principles

The m ost c o m m o n ty p e o f soft c o u n te rin g uses relaxation training.

Clients are first instructed in a n y o n e o f th e m a n y typ es o f relaxation,
and then c o u n te rin g te c h n iq u e s are em p loyed . T he m ost crucial ele­
Countering Techniques: S o ft 133

m e n t in u sing this te c h n iq u e is to b e sure that clients rem ain calm

th ro u g h o u t th e procedure.
The techniqu e pairs relaxation with anxiety-provoking stimuli to
inhibit conditioned anxiety responses. This is similar to cou nter condi­
tioning— a procedure that pairs a positive to a negative stimulus so that
th e positive replaces the negative. In order for the procedure to work, the
positive stimulus m ust b e stronger th a n the negative. This is achieved by
exposing the subject gradually to the feared event. Schematically, nega­
tive and positive conditioned responses look like this:

CS--------------------------------------------------- ►- C R -
C S + ------------------------------------------------ ► CR+

After pairing a strong C S+ w ith a w eaker C S - we have:

CS ------------------------------------------------- ► CR+

In th e traditional co u n te r-co n d itio n in g approach, the C S - consists

o f a series o f an x ie ty -p ro d u cin g im ages that are arranged in a gradu­
ated hierarchy. These im ages are paired w ith relaxation until the
relaxed resp on se substitutes for the anxious one.
Cognitive restructuring modifies this procedure by desensitizing
client beliefs instead o f their images, thus reducing or elim inating any
n eg ativ e e m o tio n co n n ected to th o se beliefs. Im ages are used only to
provide a co n tex t or b ack g ro u n d for visualizing different beliefs.

M eth o d 1
1. Initially th e client is trained in o n e o f th e several available m ethods
o f relaxation. These include standard relaxation, applied relaxation,
EMG, GSR, pulse rate reduction, white or pink noise, alp h a-th eta
relaxing scripts, natu re sounds, and self-hy pnosis (see Further
Inform ation).
2. D evelop a hierarch y o f irrational beliefs that are causing an xiety
O rd er th e hierarch y by degrees o f fear the thoughts elicit o r how
strongly th e th o u g h ts are believed.
3. Instruct th e client to im agine th e least provocative thou ght o n the
hierarchy. W h e n this th o u g h t is clearly in mind, b egin deep muscle
relaxation. C ontinu e with this proced ure until th e client's tension
level retu rns to zero, indicating that th e th o u g h t n o longer pro­
duces anxiety. For exam ple:
134 The New H a n d b o o k o f C o g n it iv e Therapy Techniques

Now I would like you to th in k o f the next th o u g h t o n you r

h ie ra rc h y Picture this th ou g h t as clearly as you can. If you
wish, you can im ag in e a particular situation in th e past w h en
you have often had the thought. C o n tin u e th in k in g the
th ou g h t until it is clearly in mind. Tell m e w h e n you h a v e it by
signaling with y o u r right h a n d . . . . Okay, stop! Now relax you r­
self ju st as you h av e b e e n taught, and keep relaxing until you
feel co m fo rtab le again. Tell m e w h en you are ready. (Biofeed­
back m easures o r a verbal report can b e used instead o f a hand
signal.) Now I would like you to d o it again. T h in k th e thought,
get it clearly in mind, and then relax yourself. You can im ag in e
a scene w h ere you are likely to have th e th o u g h t if it helps you,
b u t m ake sure it's different from the o n e you used before.

4. C on tinu e th ro u g h th e client's h ierarchy o f th ou g h ts until th e a n x i­

ety for all item s is zero.
5. Tape th e p roced u re so th e client can practice at h om e.

M eth o d 2
You can v a ry y o u r tech n iq u e by su b stitu tin g resp o n se s o th e r than
r e la x a tio n . You c a n u se p o sitiv e p h y sic a l r e s p o n se s, a sse rtiv e
responses, n a tu re tapes, positive im ages th at a client finds p erson ally
reinforcing, or low heartbeat, GSR, or EM G readings.

M eth o d 3
G eneral im ages ca n also b e associated with irrational th ou g h ts as a
substitute for relaxation. In m ost cases the therapist sh o u ld h elp the
clients interw eave these im ages with th e irrational th o u g h ts in su ch a
way th at th e em o tio n a l v ale n ce o f the im age transfers to th e beliefs.
The follow ing im ages h a v e p rov en useful: Su p e rm a n , Power Rangers,
favorite h eroes a n d heroines, favorite objects, su nflow ers, lotus b lo s­
soms, sun, stars, m oon , religious figures (Christ, Buddha, M o h a m m ed ),
a wise guru, natural life forces (rivers, m o u n ta in s, oceans), w a tch in g
o n e se lf in a m ovie, visualizing o n e s e lf as a parent, adult, or child, or
im ag ining o n e s e lf as an animal.
Ideally, o n e o r m o re o f th ese positive im ages are interw oven with
th e negative belief. For instance, in terw eav in g th e th o u g h t, "I need to
b e b e tte r th a n ev ery o n e else," w ith the feeling th a t a client has toward
children m ay b rin g h o m e th e idea th at a child is w o rth w h ile even
th o u g h an adult m ay b e stron ger and w iser and m a y h a v e achieved
Countering Techniques: Soft
/

m ore. Therefore, b e in g su p e rio r is not a prerequisite for b ein g w orth­

w hile. Similarly, th e Power R a n g er im age could b e interw oven with
the th ou g h t, "I a m inferior to o th e r girls b eca u se I c an 't ride a bike."
M a n y eastern religions, includ ing Zen and Yoga, h av e used im age
d esen sitization for centuries.

E xam ple
Em ploy this co u n te rin g te c h n iq u e after a relaxed state has b een
induced.

I'd like y ou to im ag in e the n ex t scen e o n y o u r list as clearly as

you can, u sing all you r senses. W h ile im ag in ing this scene, listen
to th e irrational th in gs you tell y o u rse lf a b o u t it. C on tin u e until
you h a v e b o th th e scen e and o n e key th ou g h t clearly in mind.
Ind icate w h en y ou are ready.

(Client gives th e signal.)

Now relax completely. Let y o u r m uscles b e c o m e lo o se and

lim p to the poin t w h e re th ey feel w arm and heavy.

(Repeat parts o f th e relaxation te c h n iq u e used in the b e g in n in g o f the

session.)

In d icate w h en you are fully relaxed.

Now, I'd like you to stay in this relaxed state. If at a n y time
y ou start to feel tense, stop w hat you 're doing and relax yourself.
W h ile you relax, I would like you to talk to y o u rse lf silently, in a
soft and caring m anner. C o n v in ce y o u rse lf that y o u r thinking is
n ot true. Im a g in e that you are talking to y o u rse lf in th e way that
a lo v in g p aren t talks to a child afraid o f im agin ary m onsters in
th e b e d r o o m — you need to b e patient but firm. G ently persuade
this child that her fears are not useful.
Keep persu ad ing th e child u ntil you feel a distinct w eakening
o f y o u r old useless th in k in g and a distinct lessening o f the
u n p lea sa n t em otio n . Take as m uch tim e as you need. Indicate
w h en you are done.

This te c h n iq u e is rep eated twice more, after w hich the client again
im a g in es th e test sc e n e w h ile th e therapist m on itors the client's state
o f relaxation. If th e client rem ain s relaxed w hile im agining th e scene,
th e n ex t item in th e list is presented, and so on, until th e client can
visualize each sc e n e w ith a m in im u m o f anxiety.
 T h e N lw H an d bo o k of Co g n it iv e T h erapy T ec h n iq u es

C om m en t
If th e client b e c o m e s arou sed at a n y tim e du rin g th e proced ure,
stop the process and return to th e relaxation procedure.
We have fou n d th at the first m ethod , w h ich pairs rela x a tio n with
a n x ie ty -p ro d u cin g thoughts, is not as effective as o th e r desensitization
tech n iqu es. S o m e clients, particularly ag o rap h o b ics, get a n x io u s w h en
trying to relax ("I m ay lose control"). In addition, relaxation is a p h y s­
iological se n so ry response, w h ile th o u g h ts are cognitive. Thus, this
m e th o d m ixes tw o very different perceptual m od es, w h ich se em s to
dilute th e effectiveness o f th e tech n iqu e. T h e b est su b stitu te resp onse
is in the sam e m o d e as the original negative c o n d itio n e d stim ulus
(visual, auditor)', kinesthetic, sensory, or em otional). For this reason,
th e third m ethod, w hich co u n te rs negative th o u g h ts with positive
thoughts, is u su ally th e m ost effective.

F u rther In fo r m a tio n
This te c h n iq u e is sim ilar to so m e o f W olpe's desensitization p ro c e ­
dures, b u t w ith a dose o f co g n itio n (W olpe 1958, 1969, 1973; W o lp e &
Lazarus, 1967; W olpe, Salter, & Reyna, 1964). His later w o rk (Wolpe,
1978, 1981a, 1981b; W olpe, Lande, McNally, & Schotte, 1985) sh ow s that
h e recognizes the im p o rta n ce o f cogn ition s in s o m e c o n d itio n in g
processes.
Therapists can u se a n y form o f relaxation. T h e re are m o u n ta in s o f
books, m anu als, and tapes o n th e su bject. Tapes can b e fo u n d from
Davidson (1997) an d CDs from Relaxation C o m p a n y (1996). R elaxation
with a c o g n itiv e -b e h a v io ra l spin can b e o b ta in e d from Sm ith (1990)
and you can find a c o m p le te listing from Sutcliffe (1994). Please don 't
forget the w ork o f the o rig in ato r o f th e relaxation tech n iq u e, Ja c o b so n
(1974), and the sh o rter version o f his w o rk b y W o lp e (1975). O st has
created applied relaxation and has c o m p a red its effects to cogn itiv e
therapy (Ost & Westling, 1995).

A n t ic a t a st r o ph ic P r a c t ic e

Principles

Because m ost p e o p le a r c co n sisten t in th eir thinking, in different

situ atio ns an d at different tim es a client m a y distort reality in th e sam e
way. T he m ost c o m m o n ty p e o f distortion is catastrop hizing, the
 Countering Techniques: Soft
/

e x tr e m e e x a g g era tio n o f im p en d in g doom . M a n y clients o b serv e a

m in o r th reat in th e e n v ir o n m e n t a n d b eliev e th e w orst co n ceiv a b le
d a n g e r is im m in en t. After years o f practice, their exaggerations
b e c o m e h a b itu a l, cau sin g c h ro n ic a n x iety and a con stan t dread o f the
e n v iro n m en t.
W h a t th ese clients fail to recogn ize is that the word catastrop he
im plies a great calamity, m isfortune, o r disaster. A lthou gh clients m ay
accu rately perceive s o m e d a n g er in a giv en situation, in catastrop h iz-
ing they grossly exagg erate the degree o f danger, a lo n g with its p o ten ­
tial for d am age. T heir brains exp an d pain into torture, em b arra ssm en t
into disgrace, an u n p lea sa n t e x p e rie n c e into an in to lerab le one.
1 h e b est co u n te rs to catastrop hic beliefs e m p lo y soft countering, in
w h ich clients u n d ercu t th e high em o tio n a l energy invested in irra­
tio n a l th o u g h ts b y relaxin g a n d calm ly thin kin g o f the best co n ce iv ­
a b le o u tc o m e th ey c a n im agine. T h e new interpretation overcorrects
th e n eg ativ e e m o tio n caused by th e catastrophizing, im proving the
p ro b a b ility that th e final affective resp onse will ap p ro x im a te reality.

M eth o d
1. List th e situ atio ns th e client catastrophizes.
2. Record the d a m a g e th e client anticipates for each situation.
3. O n a c o n tin u u m from 1 to 10, record the extent o f d am age that the
client anticip ates (1 eq u als n o d am ag e and 10 equals horrific d a m ­
age).
4. A fter discu ssin g cou ntercatastroph izing, ask th e client to im agine
th e b est p ossib le o u tc o m e th a t could h a p p en in each o f th e situa­
tions. Record this o u tc o m e o n the s a m e 1 to 10 contin uu m .
5. H ave th e client decide, based on past exp erience, w h e th e r th e catas­
tro p h e o r b est possible o u tc o m e is m ost likely to occur.
6. W h e r e appropriate, h av e th e client use the c o n tin u u m to predict
d a n g er in u p c o m in g situ ations th at are feared. After th e ev en t actu ­
ally occurs, h av e th e client check th e scale to see w h e th e r th e antic­
ipated level o f d a m a g e occurred.
7. Clients sh o u ld practice cou n tercatastro p h iz in g regularly until they
c an m o re realistically assess anticip ated dam age.

E x a m p le : T he Story o f Dean
Dean, a to p b u sin essm a n , was referred to m e b y his private physi­
cian. He was u n u su a lly successful, havin g expertly advised m a jo r c o r -
138 T h e N ew H andbook of Cq g n iim T h erapy T ech niq ues

p o ra lio n s w o rldw id e for m a n y years. Despite this, h e suffered from

ch ro n ic a n x iety and had p an ic attacks b e fo re each p resentation. A year
and a h a lf o f ch lord iazep oxid e treatm en t had not red uced his anxiety.
As is typical with this typ e o f anxiety, D ean th o u g h t th e s a m e co re
b e lie f b efo re each presentation. He im ag ined th a t his h ead w ould start
sh ak in g b e c a u s e he was nervous, a n d all th e co rp o ra te ex ecu tiv es
would discover that h e w asn't th e cool, calm profession al h e pre­
ten d ed to be. He im a g in ed this tic w o u ld d estroy his facade, an d th at
ev ery o n e in th e a u d ien ce w ould see his "cowardice."
This m an's deeply rooted co re b e lie f was th a t h e was b a sic a lly infe­
rior and needed to h id e b e h in d a c o m p e te n t facade. Letting o th ers see
b e h in d th e facade w ould m e a n c o m p le te and in sta n ta n e o u s rejection.
The d a m a g e would b e irreparable; it w ould b e th e w orst possible
th in g th a t c o u ld ev er h a p p e n to him.
Dean's core attitude can b e b ro k e n dow n in to specific su b -b eliefs,
as follows:

1. Everyone in th e a u d ien ce will ig n o re w h at I am say ing th e m in u te

th ey see m y h ead shake.
2. T h ey will kn ow that I am a total fake a n d will n e v e r b e lie v e m e
again.
3. B ecau se th e y will see m e as a sissy and n ot a real m an, th ey will
n ev er asso ciate w ith m e again.
4. Since th ese to p -le v e l execu tives w o u ld n 't w an t to b e a ro u n d such
a wimp, I will never b e ab le to give m y lectures again. 1 will lo se all
m y m a le friends, w o m e n will h a te m y w eakn ess, a n d 1 will b e c o m e
poor, alone, and destitute.

For each o n e o f Dean's th ou g h ts w e m a d e a ca ta stro p h e scale as

show n below. T h e X on each scale indicates th e ex ten t o f th e predicted
dam age, w ere th e ev ent to occur.

How catastrophic would it be i f ,

ev ery o n e saw m y tic?

I________________________________________________________________ X ______ |
1 2 3 4 5 6 7 8 9 10

th e a u d ien ce co n ce n tra te d o n it?

I------------------------------------- .----------------------------------------X_____________|
1 2 3 4 5 6 7 8 9 10
 Countering Techniques: Soft
139
/

th e a u d ie n c e th ou g h t I was a total fake?

1------------------ Y 1
1 2 3 4 5 6 7 8 9 10

the a u d ien ce knew I w as a sissy?

X |
1 2 3 4 5 6 7 8 9 10

I lost all m y incom e, a n d all m y m a le and fem ale friends?

1 Y 1
1 2 3 4 5 6 7 8 9 10

Next w e listed th e best possible things that could h a p p en and

m ark e d anticip ated d a m a g e from th e se o u tco m e s o n th e sa m e scale.
I h e o u t c o m e was that few p e o p le w ould see his tic, and those w h o did
w o u ld n 't c o n ce n tra te o n it. No o n e w ould th in k h im a fake or sissy,
and h e w ould lose n e ith e r in c o m e n o r friends. The client rated all o f
th ese o u tco m e s at a b o u t a zero d a m a g e level.
By c o m p a rin g the ratings for th e worst and b est possible ou tcom es
it b e c a m e ap p a ren t that th e client was catastrop hizing b y a factor o f
eight.
W e th e n assem b led a series o f o th e r c o n tin u a taken from Dean's
past predictions. By co m p a rin g w h a t had hap p en ed in prior situations
to w h at th e client had predicted w ould h app en, w e found th at very
little d a m a g e had actu ally occurred, and that the b est possible out­
c o m e s w ere con sisten tly closer to reality th an the worst. T h e client
could not th in k o f a single tim e o u t o f hundreds o f situations when
a n y th in g rem o te ly sim ilar to his worst predictions had occurred.
For th e n ex t 6 weeks, this m an predicted the best and worst possi­
b le o u tco m e s o f each presen tation h e was a b o u t to make, alon g with
th e estim ated dam age. T h e next day h e w ent back to his scale and
d e term in ed w hich prediction was m ost accurate. W ith o u t exception,
th e "b e st possible o u tco m e " occu rred ever)' time.

C om m en t
T h e u se o f th e c o n tin u u m isn't essential to this m ethod, b u t it gen ­
erally helps clarify th e client's level o f catastrophizing.
Clients often ask, "W hat if th e w orst thing im ag in ab le does happen,
e v e n th o u g h it's highly unlikely? Sh ouldn't I w orry a b o u t that?" In
this situation, y o u can p oin t out that if they feared all low p robabili­
m T h e N e w H andbook oe Co g n itive T h erapy T ec h n iq u es

ties th a t could occur, they w ould h av e to hide in caves to avoid m e te ­

ors, avoid crossin g streets to keep from g etting h it b y trucks, an d stop
eating food to keep from b e in g poisoned. Even th o u g h th ese things
can and do h app en , p e o p le can still b e h a p p y O u r jo b in life is to
avoid high prob ab ility dangers, n o t to avoid ever)' c o n c e iv a b le c a ta s­
trophe.

F u rth er In fo r m a tio n
Beck (Beck, 1993; Beck, Emery, & G reenberg, 1985; Beck & Zebb,
1994) states that ca ta strop h ic m isin terp retation is o n e o f th e k e y c o g ­
nitive c o m p o n e n ts for p an ic disorders. It is a central e le m e n t in treat­
ing so cial p h o b ia s in in d iv id u al and g ro u p c o g n itiv e th e r a p y
(H eim berg & Juster, 1995; Stein, 1995) an d im p o rta n t in o b se s siv e -
c o m p u lsiv e disorders (Salkovskis, 1996; Salkovskis, Richards, & For­
rester, 1995).
Catastrophic th in k in g is discussed in detail b y th e ration al em o tiv e
b eh a v io ra l therapists. See Ellis (1973, 1995, 1996), Ellis a n d Grieger
(1977), and M a u ltsb y (1984, 1990).

Co pin g St a tem en ts

Principles

M a n y clients ex p ect to fail m iserably in ev e ry th in g th e y do. B a n ­

du ra (1997) and others h av e d escribed this e x p e cta tio n as "low self-
efficacy," th e b e lie f that o n e c a n n o t ex ecu te th e b e h a v io rs requ ired to
prod uce positive ou tcom es. Clients e x h ib itin g this e x p e cta tio n co n sis­
tently u n d erestim ate their ability to c o p e w ith variou s situations. They
b eliev e th ey will fail at th eir jobs, b e rejected b y th e ir lovers, or flu nk
out o f school, and after a w h ile th ese types o f e x p e cta tio n s ten d to
b e c o m e self-fulfilling. C oping im ager)' c a n avert this pattern, h elp in g
im p rov e client self-efficacy.
Coping im ag ery is b est d o n e as a soft c o u n te r in g proced ure, ex e­
cuted in a relaxed, calm manner. It can b e distinguished from m aster)'
im agery d o n e in a n arou sed e m o tio n a l state b e c a u s e in master)', th e
clients im ag in e d o in g a task perfectly; in coping, th ey an ticip ate vari­
ou s p ro b lem s with the task, b u t also picture d ealin g w ith th ese p ro b ­
lems. C oping sta tem en ts are su p e rio r to m astery im ag ery b e c a u s e they
sensitize th e clients to possible m istakes and p rep are th em to recover
from errors th ey m a y m a k e in real situations.
 Countering Techniques: Soft
141
/

M eth o d
1. C reate a h iera rch y o f situ ation s in w hich the client is depressed or
anxious.
2. W ith th e client's help, prepare a self-talk dialogue to b e used dur­
ing th e stressful situation. 1h e d ialo gu e sh ou ld realistically antici­
p a te m ista k es, erro rs, an d n e g a tiv e e m o tio n s , a n d in c lu d e
s te p -b y -s te p instru ction s on h ow to o v e rco m e these problem s. It
s h o u ld co v e r the tim e before, during, and after the a n x io u s situa­
tion.
3. R eh e a rse the d ialo gu e out lou d with th e client for each item o n the
hierarchy. For b est results, use a m o d elin g proced ure (M eichen­
b au m , 1993, 1994) in w hich the therapist says the dialogue and the
client first repeats it, th en im agines it. M o n ito r the client throu g h­
out th e reh earsal a n d correct any mistakes.
4. E n cou rag e clients to practice their cop in g techniques, using the
m e th o d that seem s m ost effective. For instance, so m e clients find it
b en eficial to listen passively to a cassette tape o f the therapist read­
ing th e dialogue, w h ile others prefer a tape that describes each sit­
u atio n o n th e h iera rch y in detail, th us allow ing them to practice the
dialogu es covertly. Still others carry th e dialogues on index cards
and read th em w h e n faced with a real situation. In m ost cases,
clients n eed to practice th eir scripts for at least six weeks.

E x a m p le: The Story o f P aula

Paula, w h o was referred to m e b y a n o th e r psychologist, had been
a g o r a p h o b ic for two years. O n e o f th e highest fears on h er hierarchy
w as sh o p p in g a lo n e in a large superm arket; w h e n e v e r she tried to
shop , h e r a n x iety would overw helm h e r an d s h e would have to leave.
By th e tim e I first saw h e r sh e hadn't b e e n to a large store for a year
and a half.
We practiced th e follow ing d ialo gu e for several sessions. Initially we
recorded it an d s h e listened to the recording three tim es a w eek for
five weeks. Sh e then practiced the script in vivo six times, during
actual a g o ra p h o b ic situations. This te c h n iq u e finally reduced her p h o ­
b ia sufficiently so th at sh e could sh o p co m fo rtab ly in large su p e rm a r­
kets.
H er c o p in g dialogue follows:

This m o rn in g I'm g o in g to th e superm arket. I'll p rob ab ly be

ten se in th e begin n in g, b u t o n ly b ec a u se I h av e stayed away
 T h e N ew H an d bo o k of C o g n it iv e T h erapy T e c h n iq u e s

from th e store so m e tim e—h o t b e c a u s e 's to r e s are really so m e ­

th in g to fear. Stores are NOT d angerou s. Even little ch ild ren and
very old p eople g o to grocer)' stores. If stores w e re d angerou s,
they'd h av e a big w arn in g sign in front read in g W ARN IN G, THE
SU RG EO N GENERAL HAS D ETE R M IN ED THAT SU P E R M A R ­
KETS ARE DAN GEROUS TO Y O U R HEALTH.
(Paula im agines entering store.) Here I am, lo o k in g aro u n d ! It's like
every' o th e r store. There's a lot o f p ro d u ce and c a n n e d g o o d s and
meats. No o n e in th e history o f th e world has ev er b e e n attacked
by a can o f peas. Still, I feel a little n erv o u s inside. Since stores
don 't h av e th e pow er to crea te fear, it m u st b e s o m e th in g I am
telling myself. Let's see w h a t su perstitious n o tio n I a m b u y in g
into. Ah, yes! It's th at s a m e old idiotic th o u g h t— th a t I'm g o in g to
lose co n tro l and em barrass m y se lf in front o f all th ese people.
G old en oldie bullshit! I h av e b e e n saying this n o n s e n s e to m y se lf
for tw o years, I h av e n ev er lost c o n tro l and I n ev er will. It's ju st
a stupid g a m e I play w ith myself, like preten d in g if I put m y fin­
g e r in m y ear, m y n o se will fall off. T hese p e o p le h av e m o re
things to d o in this store th a n to w atch m e to see if I sh o w th e
tiniest sign o f tension. T h ey are m o r e interested in finding a ripe
tom ato. Besides, I don 't h av e to co n tro l this tension. All I h a v e to
do is b u y m y can o f su ccotash and leave— b ig deal! It d o esn 't
m atter how tense I get. M y jo b isn't to sh o p w ith o u t ten sio n ; it's
o n ly to shop. And I'm g o in g to sh o p no m a tter h ow I feel. Even
if I h a v e to crawl th ro u g h th e c h ec k o u t line o n m y h an d s and
knees, I'm g o in g to stay. M y life has b e e n ruled b y a silly su p e r­
stition lon g enough.
(Paula completes shopping, leaves store.) There, I did it! That's th e
o n ly th in g that counts. W h a t I d o in life is far m o re im p o rta n t
than h ow I feel w h en doing it. I'll keep d o in g this until I get rid
o f m y superstitions and the fear th ey produce.

C om m en t
W h ile m ost clients b en efit a great deal from practicing cop in g state­
m ents th rou g h imagery, these statem en ts ultim ately m u st b e practiced
in vivo. Otherwise, the client can sa b o ta g e th e tech n iqu e, saying, for
exam ple, "It’s very nice to think this way, b u t I still h aven't g o n e to th e
store."
W e d o n ’t b eliev e that you sh o u ld pressure clients to practice their
scripts in the e n v ir o n m e n t Until th ey h av e reh earsed th e m ex ten siv ely
 Countering Techniques: Soft
0

and covertly. 1 o do so w ould o n ly crea te m o re anxiety, increasing the

p ro b a b ility o f failure.

Further In fo r m a tio n
For early in fo rm a tio n o n cop in g sta tem en ts see Cautela (1971b),
Goldfried (1971), a n d S u in n and R ichardson (1971). A m o re th o ro u g h
in vestigation o f the th e o r y b e h in d this tech n iq u e is provided by
Lazarus, Kanner, an d F olk m an (1980), M a h o n e y (1993b), M a h o n e y and
Ih o r e s e n (1974), and M e ic h e n b a u m (1975, 1977, 1985, 1993).
C a n n o n (1998) has developed a form o f cop in g based on cognitive
reh e a rsa l using hypnosis.
T h ere is also an exten siv e b o d y o f literature on self-efficacy (see
B an d u ra 1977a, 1977b, 1978, 1982, 1984, 1995, 1997; Bandura, Adams,
Hardy, & Howells, 1980; Bandura, Reese, & Adams, 1982; Bandura &
S c h u n k 1981; and Teasdale, 1978).
M o r e in fo rm a tio n a b o u t cop in g vs. m astery im agery can b e found
in M a h o n e y and A rn k o ff (1978), Richardson (1969), and Singer (1974
1976, 1995).

C o v ert E x t in c t io n

Principles

In a classical co n d itio n in g paradigm, a client can develop a phobia

as a result o f h av in g b e e n ex p osed to a terrifying event. A ny stim ulus
p resent at th e s a m e tim e as th e fear can get conditioned, so that the
stim u lu s develops the ability to p ro d u ce the anxiety. For exam ple, a
clien t o n c e had difficulty b r e a th in g w h en h e drove his car o n a long
trip b e c a u s e c a r b o n m o n o x id e was leaking from the ex h au st system
in to th e car. His respiratory' difficulties produced a stron g anxiety
(UCR). After discovering th e leak h e repaired the car, but developed
a n x iety (CR) w h e n e v e r h e drove again an d finally stopped driving
altogether. S ch em atically his ph ob ia is:

CR = anxiety
144 T hf New Handbook of Cognitive T iiera ty Techniques

How can this con d ition ed reflex b e elim in ated ? Even th o u g h the
client stop p ed driving for several m onth s, it did n o t re m o v e th e a n x ­
iety, for w h en h e was forced to b e a p assen g er in s o m e o n e else's car,
he b e c a m e a n x io u s again. His co n d itio n e d a n x iety was n o t easily
rem oved. Theoretically, had h e c o n tin u e d driving, h e w o u ld h av e
b e e n e x p o sed to the CS w ith o u t the UCS, and his a n x iety w ould h av e
gradually disappeared. This e x p e rie n c e is called extin ction . But
b e c a u s e h e avoided driving, th e C S -U C S asso cia tio n n e v e r h a d th e
o p p o rtu n ity to b e elim inated.
To help this client w e used covert extin ction . T he clien t im ag in ed
driving w ith ou t b re a th in g p ro b lem s until h e could picture th e sc e n e
w ith o u t anxiety. After practicing this im a g e fo r several w eeks, h e was
a b le to drive again, so th a t in viv o ex tin ctio n co u ld elim in a te his p h o ­
bia. H aving th e client im ag in e th e CS w ithou t th e U CS is th e key to
covert extinction. Extin ction m ay era se th e p rev iou s asso ciation, or
new learnin g m a y replace th e old; w h a te v er th e correct ex p la n atio n ,
the p roced u re can help clients rem o v e phobias.
Beliefs as well as ex tern al stim uli c a n b e c o m e c o n d itio n e d to trau ­
m atic events. Thus, a n y th o u g h t that occu rs at the tim e o f a strong
a n x iety resp o n se can b e c o m e a CS th a t a lo n e will later elicit fear.
T herefore covert e x tin ctio n can b e u sed to d isco n n e c t th o u g h ts from
their em o tio n a l co m p o n e n ts.

M eth o d 1. B e h a v io r a l in Vivo
Have clients practice th e feared ev en t u n til ex tin ctio n takes place.
T he therapist m u st b e sure that th e U CS will n o t recur.

M eth o d 2. Covert
Have the client im a g in e d o in g th e feared activ ity w ith o u t aversive
con seq u en ces.

M eth o d 3. B e lie f Extinction

1. M a k e a list o f th e th ou g h ts th a t have b e c o m e asso ciated w ith th e
client's sou rces o f anxiety.
2. Have the client im a g in e th in k in g th e th o u g h ts in variou s situations,
b u t w ith o u t a n y n egative e m o tio n a l response.
3. T he client can practice several h u n d red rep etitio n s at h o m e until
the th ou g h ts n o lon g er p ro d u ce th e CRs.
Countering Techniques: Soft

M eth o d 4. T im e Extinction
Instruct y o u r clients to w ait until they feel happy and confident;
th e n h av e th e m read or th in k th e irrational thoughts. Tell th em to stop
th in k in g or read in g im m ed iately if th ey b eg in to feel upset. Instruct
clients not to d o th e exercise w h en they feel unhappy.

M eth o d 5 . N eutral Im a g e s
1. M a k e a list o f the client's irrational th ou g h ts and the situations in
w h ich they frequ en tly occur.
2. D evelop a list o f neu tral im ages to w h ich th e client attaches little
em otio n , su ch as lo o k in g at a new spaper, eating a m eal, or reading
a psych ological dissertation. Ask th e client to confirm that these
activities p ro d u ce o n ly neu tral em otions.
3. Pair the irrational th ou g h ts with th e neu tral scenes. You will prob ­
a b ly n ee d o v e r a h u n d red repetitions.

M eth o d 6. S h a p e d Covert Extinction

Have y o u r client im ag in e a su b c o m p o n e n t o f the CS, so that th e CR
is n o t elicited. In th e earlier exam ple, th e upset driver w ould im agine
sitting in th e driver's seat, o r h o ld in g the steering wheel in his hands.
Since th e CS is not at full strength, the CR n ev er occurs a b o v e thresh­
old. Gradually, m o re and m ore o f th e CS is presented, always b elow
thresh old , until the full CS causes n o response. Specifically:
1. M a k e a list o f the client's irrational thoughts.
2. Logically dissect th e th ou g h ts into su b co m p o n e n ts. For exam ple, if
th e client's th ou g h t is "I a m w orthless if I keep failing at things." You
can su b d iv id e "things" into a variety o f different failings, like b reak ­
ing y o u r pencil, forgetting to put o u t th e cat, dropping a stitch, etc.
3. H ave th e client im age the su bparts o f the thou gh ts for m a n y rep e­
titions. M a k e sure that this focus on th e su bparts causes no dis­
com fort. You can use a b io fee d b a ck m easu re or client self-rep ort to
d e te r m in e w h e th e r the client is feeling the CR. If a CR occurs, su b ­
divide th e th o u g h t further.
4. Provided th at there is n o em o tio n a l response, keep building the
th o u g h t clo ser to its original form. C on tin u e until th e entire origi­
nal th o u g h t prod u ces n o negative em otions.
5. A n o th e r form o f sh ap ed covert extin ction varies the fear-p rod u cin g
im a g e rath er th an th e thou gh t. For exam ple, fear o f riding in an ele­
v a to r can b e su b d ivid ed b y im ag ining a big elevator, a glass one, an
146 T h e N e w H and bo o k .,.o f. Co g n itiv e T h erapy T ec h n iq u es

em p ty elevator, o n e th at g o e s up o n ly o n e flo o r or o n e th a t travels

4 0 floors. T he im age can also b e varied b y c h a n g in g clients' per­
spectives o f them selv es in th e p h o b ic situation. Clients can picture
them selves in the elevator on TV, lo o k in g b a ck from the future, in
an a u d ien ce with friends w atch in g a play o f them selv es in th e ele­
vator, etc. In all cases, th e s u b c o m p o n e n ts o f the im ag e are pre­
sented so th a t clients' em o tio n a l resp on ses r e m a in b e lo w threshold.

M eth o d 7. M orita T h erap y

M o rita therapy, created at the b e g in n in g o f this century, is a Ja p a n ­
ese th erap eu tic te c h n iq u e based on ex tin ctio n procedures. Clients suf­
fering from d y sth y m ic disorders are isolated in a ro o m for th e first
week. During this tim e th ey h av e a n x iety an d d epression, b u t they
c a n n o t escap e o r avoid th eir discom fort. T heir CRs are n o t in te n tio n ­
ally exacerb ated as in flood in g; instead, clients sim p ly e x p e rie n c e th eir
thou ghts and im ages a n d let the c o n se q u e n c e s occur. Sin ce the im ag­
ined c o n se q u e n ce s (e.g., death, insanity, total loss o f control) d o not
occur, ex tin ctio n takes place. A cogn itiv e c o m p o n e n t that h elp s the
extin ction process is th e instru ction : "W h a t o n e thinks, im agines, or
feels is less im p o rtan t th a n w h a t o n e d o e s in life. A person can c a m '
on an active, p u rposefu l life, despite th e b u rd e n o f sym ptom s." This
p h ilosop h y h elp s clients realize that there a rc no u ltim a te U C Ss to
thinking and feeling and, therefore, th ere is n o reason to avoid
th ou g h ts o r em otions.

E x a m p le : T he Story o f K erin
S o m e years ago, Kevin c a m e to m e b e c a u s e o f severe p a n ic attacks.
T he o n ly e n v ir o n m e n ta l trigger w e could find was that his college
r o o m m a te h a d quit sch ool, leavin g h im alo n e in th e a p a rtm e n t they
had previously shared. After so m e exp loration , w e fou n d the possible
cause o f his severe reaction to this c o m m o n ex p erien ce. Kevin
described an e x p e rie n ce in w h ich h e a lm ost d row ned w h e n h e was 11
years old.
He and his parents had b e e n sw im m in g in th e G u lf o f M ex ico , in a
spot w h ere u n d erw ater c a n y o n s p ro d u ced b a c k curren ts th a t could
pull a sw im m e r o u t to sea. Kevin r e m e m b e r e d stan d in g in w a te r up
to his neck, trying to see w h ere his parents were. Su d d en ly a large
w ave hit h im an d dragged h im into o n e o f th e u n d e rw a te r can yons.
T h e cu rren t was s tro n g and Ije co u ld n 't sw im ag ain st it— h e w as b e in g
Countering lechniques: Soft 147
/

pulled o u t to sea. Fortunately, a lifeguard on sh ore saw w hat was hap­

p e n in g a n d rescu ed him.
A fter th e ex p erien ce, Kevin had b e c o m e very afraid o f the ocean,
and his fear h a d generalized to lakes, rivers, and large sw im m ing
pools; h e avoided th em all. This was a rather typical incident creating
a q u a p h o b ia . Schem atically:

CS = o c e a n an d generalization
to large b o d ie s o f
CR = anxiety

U CS = a lm ost drow ning

W h a t Kevin was n o t aw are o f was that a n o th e r association had also

occu rred . Not o n ly had h e b e e n in w ate r w h en the panic appeared,
b u t h e had also b e e n th in kin g that he was all alone. He had noticed
that h e cou ld n 't see his parents and th at there was n o o n e else around.
Ever sin c e th at incident h e not only feared w ater b u t he also feared
b e in g alone. He recalled b egg in g his parents not to g o out w ithout
him a n d d e m a n d e d that h e not b e left in the h ou se b y himself. W h en
his r o o m m a te had left, he'd found h im s e lf a lo n e for an exten ded time.
Schem atically :

I- CS 1 = o c e a n and w ater
CS 2 = th ou g h t o f b ein g
CR = anxiety
paired

U CS = alm ost drow ning

— CS 3 = e n v ir o n m e n ta l trigger (ro o m m a te leaving)

CR = anxiety
paired

CS 2 = th ou g h t o f b e in g alo n e
148 The New H a n d b o o k o f C o g n it iv e Therapy Techniques

We used several coverl ex tin ctio n m e th o d s to re m o v e th e anxiety.

Kevin listened to a series o f tapes in w h ich h e im ag ined th in k in g h e
was alone. T h e scenes ranged from im a g in in g h im s e lf a lo n e in the
b a th ro o m to b e in g a lo n e o n a S o u th Pacific island w ith n o o n e w ithin
a th o u sa n d miles. W ith each im ag e h e was told to th in k th e th o u g h t
for as long as h e could w ithou t a n y negative co n se q u e n ce s. I f h e
b e c a m e upset or h e im agined so m e n eg ativ e c o n s e q u e n c e to b ein g
alone, h e was told to stop th e scen e im m e d ia tely and d o it again until
h e could th in k the th ou g h t in the sc e n e w ith ou t gettin g a n x io u s
(shaped covert extinction).
He was also instructed that ou tsid e o f th e a b o v e ex ercise h e was to
o n ly th in k a b o u t b ein g a lo n e w h e n h e was feeling g o o d an d s e lf-c o n ­
fident (tim e extinction).
After th e covert treatm en ts h e was told to sp e n d m o re tim e alone.
He gav e h im s e lf poin ts for each h o u r h e sp en t b y h im s e lf w ith o u t get­
ting anxious, and tried to in crease his points each week. He was told
to stop if h e b e c a m e a n x io u s (in vivo extinction).

C om m en t
O n e o f th e difficulties w ith cov ert ex tin ctio n in clinical practice is
that it is o ften very difficult to keep the UCS from en terin g th e client's
thoughts. It's hard for clients to im ag e a negative scen e w ith o n ly n e u ­
tral con seq u en ces. In m ost cases covert e x tin ctio n is used in c o n ju n c ­
tion with a cou n terin g or perceptual shift tech niqu e.

F u rther In fo r m a tio n
Cautela was o n e o f th e originators o f covert ex tin ctio n proced ures
(see A scher & Cautela, 1972; Cautela, 1971a; G o testa m & M elin, 1974;
and Weiss, Glazer, Pohorecky, Brick, & Miller, 1975.) A related co n ce p t
is Beck's (1967) n eu tralization and h ab itu a tio n te c h n iq u e (Sokolov,
1963).
Eye m o v e m e n t desensitization m ay have an ex tin ctio n c o m p o n e n t.
W h e n th e old im age (the pivotal picture) is b ro u g h t in to aw areness
and associated with sciatica ey e m o v em en ts, th e e m o tio n a l c o m p o ­
n e n t m ay b e reduced b e c a u s e the original CS is o n ly partially pre­
sented, thus yielding o n ly a partial and m uch d im in ish ed CR.
However, there are m a n y o th e r p ossib le e x p la n a tio n s fo r th e active
elem en t o f EM DR (see Shapiro, 1995, 1998).
A su bpart o f sh ap ed cov ert ex tin ctio n is th e m a jo r p h o b ic trea tm en t
Countering Techniques; Soft
/

o f neu rolin g u istic p ro g ra m m in g practitioners. Clients im agine seeing

a m o tio n picture o f them selv es in th e p h o b ic scene. The scen e is var­
ied b y im ag in ing it in b lack and white, as a still picture, run in fast
forward, backw ards, view ed b e h in d a p rojection b o o th , etc. (see B a n -
dler, 1992, 1996; B and ler & Grinder, 1979, 1996; M illiner & Grinder,
1990).
M orita therapy has b e e n discussed in a n u m b e r o f publications (see
Fujita, 1986; M orita & Kondo, 1998; Reynolds, 1976, 1981).

N o n pa t h o l o g ic a l T h in k in g

Principles

C ognitive restructuring therapy, like cognitive b eh a v io ral therapy

in general, b a ses its tech n iq u es o n th e ex p e rim en ts and assum ption s
o f learn in g theory. In all o f its m a n y variations, learning theory avoids
th e use o f th e m edical m od el to describe clients' problem s. M an y
clients, however, su b scrib e w h o leh ea rted ly to the illness model.
These clients v iew strong em o tio n s as signs o f an unpleasant, if
neb u lou s, c o n d itio n th ey call "sick." Because they use this word, they
are m o re likely to display th e e m o tio n s and b eh a v io rs that th e "sick"
lab el elicits. Initially, th ey sim p ly th in k them selves em o tio n ally crip­
pled, u n b a la n ce d , diseased, or in so m e way deranged for feeling
stron g em otio n s. But th en th ey start to play th e part, acting out the
role o f th e patient with all th e a c co m p a n y in g b eh av io ral and cogn i­
tive m an ifestatio n s such as passivity, helplessness, and exp ectin g the
d o c to r to cu re them.
B ecau se o f th e d am a g in g effects o f the "sick" label w h ere it doesn't
b elo n g , this th o u g h t shou ld b e o n e o f the first o n es the client attacks.
Soft c o u n te rin g is often the b est veh icle for ch an gin g pathological
labeling.

M eth od
1. D evelop a m aster list o f core beliefs co n n ec ted to the client's n eg a­
tive em otions.
2. G o o v e r each b e lie f w ith th e client and identify a n y sign that the
client is im p lyin g a psychological sickness.
3. Explain in detail th e in app ropriateness o f th e disease label, and
su b stitu te c o m p o n e n ts o f th e learn in g theory m od el for each belief.
4. T h ro u g h o u t all o f y o u r th era p y sessions, help th e client c h a n g e any
150 T h e N e w H andbook of Co g n itive T h erapy T ec h n iq u es

th ou gh t o r word th at implies sickness. Listen fo r w ords like

"deranged," "m en tally unsound," "crazy," "unbalanced ," "falling to
pieces," "n ervou s breakdown," "freaking out," "ill," "sick," "unhealthy;'
"disturbed," etc.
5. Su bstitute a social le a rn in g m od el for a m edical m od el. Treat clients
as stu den ts u n d e r you r tutelage, n ot as patients u n d e r y o u r care.
Expect clients to d o th e h o m e w o r k you assign, to study y o u r prin­
ciples, and to ch allen g e you if they disagree. M a k e it clear th at you
con sid er cou n selin g to b e a jo in t project, 50/50. You instruct; th ey
study.

Before n eu ro tic clients e n te r into th era p y w ith me, I g iv e th e m a

sh eet that describes th e kind o f th erap y I do, w h at I ex p e ct fro m them ,
and w h a t th ey can ex p ect from me. H ere are s o m e excerpts:

M y Sendees
As y ou know, I practice a particular ty p e o f cou n selin g . You
and I m u st d ecid e w h eth er m y th erap y is th e b est ty p e for you.
If not, I will help you get th e right kind. R em em ber, a recent sur­
vey found that there are o v er 2 5 0 different types o f therapy
(Corsini, 1981, 1994).

M y Philosophy
I don 't view o u r relationsh ip as d o cto r-p a tie n t, fr ie n d -c o n fi-
dant, leader-follower, or g u ru -n o v itia te ; I v iew it as t e a c h e r -s tu -
dent. It is m y jo b to give you, as clearly as I can, th e to o ls to solve
y o u r ow n problem s. It is y o u r jo b to use th e tools. W e are eq u al
partners in you r growth.

Openness
Sin ce w e are partners in y o u r grow th, you h av e a right to
kn ow w h at I a m doing, w h y I am d o in g it, h ow lon g it will take
a n d w h at I th in k are th e causes and solu tion s to y o u r problem s.
I am not a witch d o cto r w h o uses secret, m y stical m e th o d s to
cure people. I w ant you to kn ow w h a t I think, so alw ays feel free
to ask m e a b o u t w h at I a m d o in g and why.

General
I will d o ev eryth in g I can to help y ou b y u sin g sta n d a rd te c h ­
n iqu es and develo p ing new o n e s if th e old o n es h a v e n 't worked.
If, despite o u r m u tu al effort, th e c o u n s e lin g d o esn 't help you, I'll
do m y b est to refer you to .so m e o n e else w h o can help y o u more.
Countering Techniques: Soft 151
/

E x a m p le: The Story o f Beth

For tw o years, Beth had severe generalized anxiety attacks, during
w h ic h s h e w as com p letely im m obilized. By the tim e sh e c a m e to m e
for trea tm en t s h e had b e e n in analysis for six years, th ree tim es per
week. O riginally sh e h ad entered analysis to w ork out her g rie f and
a n g e r o v er th e early loss o f her parents. After their deaths sh e had
b e e n se n t as a n ad olescen t to live with her a u n t a n d uncle, w h o m she
d escribed as rigid and rejecting. Sh e believed th at the analysis had
h elp ed h e r to c o p e w ith h e r g rie f and anger, and was puzzled w h en
after fou r years o f therapy, h er a n x iety attacks b eg a n . During her last
tw o years o f analysis t h e y h a d b e c o m e progressively worse.
T h e first step in Beth's therapy w as to persuad e her that a m ore
directive, cognitive a p p ro a ch to th erapy w ould red uce h e r anxiety,
th o u g h th e style w ould differ significantly from th e analysis sh e had
u nd erg one. Second, w e exp lored the cognitive triggers for h er anxiety,
w h ic h seem ed to b e an offshoot o f her analytic therapy. During o n e
session with h er analyst, sh e had m isu n d erstood w hat h e had said
a b o u t th e id, w h ich in tu rn caused her to b eliev e that deep down
in sid e h e r u n co n scio u s sh e was a very sick and potentially crazy per­
son. As s h e said, "It's like an evil force inside o f m e could take m e over
at a n y time. I h av e to con stan tly guard against th ese u n con scio u s
im pu lses so that th ey don 't take m e over.”
This th o u g h t w ould o c cu r w h e n e v e r sh e felt em otio n s like anger,
fear, o r sadness. Sh e w ould im m ed ia tely label these feelings as sick,
u n con scio u s, an d dangerou s, then have an a n x iety attack b ec a u se she
feared losing control. In m ost cases, h e r em o tio n s were perfectly n o r­
m al and could b e u n d ersto o d in th e co n text in w h ich th ey had
occu rred . However, sh e had a great deal o f difficulty seeing this, insist­
in g instead that h e r feelings w ere a sign that h e r u n con scio u s was
a b o u t to erupt.
Beth's a n x ie ty w as elim in ated after n in e weeks o f practice using
c o u n te r ind ex cards, listening to au diotapes, and m en tally rehearsing
beliefs th at didn't m a k e h e r seem as sick. Following are so m e o f the
situ atio n s sh e initially m isread and later reinterpreted.

Situ ation 1
S h e g o t a n x io u s du ring pian o recitals in front o f m a n y people.
Pathological Thought
I am an x io u s and scared b e c a u s e o f s o m e th in g sick goin g o n in my
u n con scio u s.
152 T h e . N e w H a n d b o o k .q f C o g n it iv e T h e r a p y T e c h n iq u e s .

R ational Belief
I am an x io u s a b o u t m essing up in front o f m y friends.

Situation 2
S h e g o t angry after h e r boyfrien d canceled his d ate fo r th e third w eek­
end in a row.
Pathological Thought
I m u st guard against m y u n co n scio u s a n g e r b e c a u s e it m a y eru p t and
m a k e m e g o crazy.
R ational Belief
I a m an g ry b ec a u se h e isn't con sid erin g m y feelings, an d I h aven 't
b e e n assertive e n o u g h to tell him.

Situation 3
Sh e had an a n x iety attack after reading a novel a b o u t s o m e o n e h a v ­
ing a nerv ou s breakd ow n.
Pathological Belief
D eep dow n inside I am sick and unstable, possessed b y o v erp o w erin g
forces.
R ational Belief
I am afraid b e c a u s e 1 th in k 1 m a y b e u n sta b le— n o t b e c a u s e I am.
There is n o th in g deep dow n inside me, o th e r th an b lo o d , b o n e s, and
tissues, ju st like ev ery o n e else. These m asses o f cells d o n 't h av e th e
qu ality o f psychological sickness a n d th ey h av e n o m ystical p o w e r o f
possessing th e rest o f me. R eading th e b o o k rem in d ed m e o f m y
superstitious fears— fears that h a v e n o th in g to d o w ith an ab straction
called th e u n con scious. I have created this ab straction in m y mind,
called it sick a n d a b n o rm a l, then told m y se lf it's g o in g to take o v e r the
rest o f me. M y fear co m es directly from w hat I say to myself, n o t from
so m e m ystical part o f m e that m y im ag in atio n has created.

C om m en t
This is an ex cellen t te c h n iq u e for clients w h o h a v e a n e u r o tic dis­
ord er b ased o n co n d itio n e d anxiety, n eg ativ e rein fo rce m en t histories,
o r m alad ap tive cognitions. However, it is a terrible te c h n iq u e for
clients w h o h av e a b io ch e m ic a l c o n d itio n th a t m ay b e g e n e ra tin g their
problem . Psychotic patients, a lc o h o l a n d drug d e p e n d e n t clients, and
th o se with m ed ically b ased b ra in disorders n eed to learn to a c ce p t and
co p e with th eir p rob lem s— not d e n y th em . It is a n tith e ra p e u tic and
dam agin g to tell a m an ic, ijio o d disorder patient w h o se p ro b lem is
Countering Techniques: Soft 153
/

cau sed b y h y p o th y ro id ism th at h e can talk, relax, or th in k his p ro b ­

lem s away. See th e sections o n treating seriously m en tally ill patients
a n d cogn itiv e restructuring th erap y with addicted patients in chapter
12 for m o re inform ation.
In th e last 15 years there has b e e n general support for a reciprocal
in tera ctio n b e tw e e n cognitive factors a n d biological functioning. It is
im p o rta n t that th e therapist differentiates b e tw e e n th e part o f a
client's p rob lem that is learned and the part that is physiologic.

Further In fo r m a tio n
M a n y a u th o rs argu e against the use o f the term "sickness" for
learn ed psychological p rob lem s (see Korchin, 1976; R abh n, 1974; Skin­
ner, 1953, 1974, 1991; Szasz, 1960, 1970a, 1970b, 1978, and U llm an n &
Krasner, 1965, 1969). T he differences b etw e en th e two views for psy­
c h o p a th o lo g y c a n b e found b y review ing the em pirical research o f
Haaga, Dyck, and Ernst (1991, a n d th e su m m ary o f research b y Fowles
(1993).

C o v ert R e in fo r c em en t

Principles

Soft c o u n te rin g often uses reinforcing beliefs. Cognitions have

m a n y fu n ctio n s in a rein forcem en t paradigm ; they can serve as rein­
forcers (e.g., "I did a g o o d job"), as a resp onse ("I got a pay raise
b e c a u s e I am a g o o d worker"), o r as a discrim in ating stim ulus ("W hen
I am self-con fid en t, I do b e tte r w o rk and m y b o ss c o m p lim e n ts me").
If a rational b e lie f is reinforced in the presence o f a specific en v iro n ­
m en tal stim u lu s (such as getting a pay raise) and an irrational b e lie f is
not, th en th e rational b e lie f will b e m ore likely to recu r in th e future,
and the irrational b e lie f less likely to do so. Covert rein forcem en t
rew ards th e client's rational beliefs. Schematically, this idea can be
illustrated as follows:

S d --------------------------------Realistic B e l i e f --------------------------R einforcem ent

S ------------------------ Irrational T h o u g h t ---------------------- No R einforcem ent

T h e follow ing th erap e u tic tech n iq u es are availab le for helping

clients to positively reinforce their ow n rational beliefs.
154 T h e N ew H an d bo o k of C o g n it iv e T h e r a p y T f c h n io i i f s

M eth o d 1. B est P o ssib le B e lie f

1. Create a h iera rch y o f p ro b lem situ atio ns a n d th eir a c c o m p a n y in g
th ou g h ts— a b o u t 10 or 15 items.
2. Develop a list o f rational beliefs for each situation.
3. Have clients im ag in e the ideal way o f h a n d lin g each situ ation in a
relaxed em o tio n a l state. Have th em picture th em selv e s th in k in g the
m ost rational, realistic beliefs possible w h ile in th e situation, and
have th em env ision the resulting e m o tio n s a n d b e h a v io r as o u t­
grow ths o f th e n ew thinking. T he therap ist m ig h t say:

Im ag ine th e scene, b u t this tim e picture y o u r s e lf th in k in g

the realistic th ou ght. Picture it as clearly as you can. . . . Now
im ag in e th a t you are feeling realistic e m o tio n s and are acting
appropriately. Keep im ag inin g this until you c o m p le te the
w h ole sc e n e th in king th e correct th ou gh t a n d feeling and act­
ing in the way that you w ould l i k e . . . . Keep d o in g it until you
can picture th e w h ole sc e n e easily.

4. After th e a b o v e im age is clearly in mind, h av e clients im a g in e th e

b est possible c o n se q u e n ce s o f th inkin g this n ew thou gh t, n o t o n ly in
th e situation b u t in all situ ation s like it.

Okay. Now create a picture o f th e b est p ossib le c o n se­

q u en ces o f th in kin g this way. Im a g in e th a t you th o u g h t real­
istically in all situations like this. W h a t really g o o d things
w ould h ap p en to you ? How w ould y o u r life b e b etter? Don't
ju st th in k o f w hat w ould h app en , b u t try to picture it h a p ­
p e n in g ------Keep d oin g it until it is clearly in m ind.

5. Repeat the exercise a m in im u m o f three tim es at each sitting. C on­

tinue until clients report no negative em o tio n al reaction w h en imag­
ining the original scene. Self-report o r b iofeed back can b e used to
assess clients' response levels.
6. C o n tin u e th e exercise, m o v in g upward th ro u g h th e h ie ra rc h y that
was established in step 1. *
7. This exercise is u su ally taped, a n d clients are told to practice at least
th ree tim es a week.

M eth o d 2. S ta n d a r d R ein fo rcin g I m a g e s

This tech n iqu e uses the sa m e steps as the a b o v e p roced u re except for
step 4. Instead o f having clionts develop their ow n images o f th e best
Countering Techniques; Soft 155
/

possible co n seq u e n ce s o f rational thinking, the therapist does that task.

This m odification is helpful for clients w h o might have difficulty con ­
structing positive images w ith sufficient intensity to b e self-reinforcing

Im a g in e as you think m o re and m ore realistically that you start

g a in in g c o n fid e n c e in yourself. Difficulties that used to b e prob ­
lem s you n ow resolve w ith relative ease. Career, finances, and
relationsh ips all start im proving. W h e n p ro b lem s occur, you
rationally h a n d le th em and m ov e o n to n ew goals. You start
reach in g and ach iev in g all those goals and o b je ctiv e s that you
h av e set for yourself.

M eth o d 3. E xtern al R ew a rd s
Clients' rational beliefs can b e reinforced using external rewards.
U sing th e P rem ack (1965) principle, a n y b e h a v io r th at has a high
prob ab ility o f b e in g ch osen (eating a ca n d y bar) m a y serve as a posi­
tive r e in fo r c e r fo r lo w -p r o b a b ility b eh a v io r (th in k in g ra tion al
thoughts). Hence, a client m ight c h o o s e to rew ard him self w h en ev er
h e replaces an irrational th ou g h t w ith a rational one.
Clients can in ten tio n ally pair positive reinforcers with desired
th ou g h ts and b eh a v io rs w h e n e v e r th ey wish, and shou ld b e en co u r­
aged to practice d o in g so. In their practice, th ey shou ld b e encou raged
to allow sm all rew ards to a c cu m u la te to b igger rewards, dep end in g
u p o n th e m ag n itu d e o f the perceptual and b eh a v io ra l hurdles that
th ey are a ttem p tin g to leap. Hence, a can d y b ar m ight b e sufficient for
a sm all hurdle, b u t th e client m ight need to set th e goal o f taking a
m a jo r vacation as a reward for o v erco m in g a truly m a jo r hurdle.

C om m en t
In m a n y cases, clients find it difficult to rein fo rce them selves. They
m a y b e m o re inclined toward self-d ep reciation than self-rein force­
m ent, m a k in g it n ecessary for therapists to help th em discover th e rea­
sons b e h in d this inclination. Therapists often h av e to give clients
p erm issio n to b e nice to them selves.

F u rther In fo r m a tio n
This t e c h n iq u e is called self-rew a rd in p re v io u s p u b lica tio n s
(Casey & M u llin , 1976, 1985; M e M u llin, Assafi, & C h ap m a n , 1978; Me
L56 T h e N ew H an d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

M u llin & Casey, 1975; M e M u llin & Giles, 1981).

M a n y researchers h a v e e x a m in e d th e effects o f cov ert rein force­
m en t: A u b u t a n d Lad ou ceu r (1978), B ajtelsm it & G e rsh m a n (1976),
Bistline, Jarem ko, and S o b le m a n (1980), B ru n n and H ed b erg (1974),
Cautela (1970, 1971b), Engum , Miller, an d M eredith (1980), Flann ery
(1972), H o m m e (1965), Krop, C a lh o o n , and V errier (1971) L ad o u ceu r
(1974, 1977), M a h o n e y (1991, 1995a, 1993b), M a h o n e y , T horesen , and
D a n a h e r (1972), S c o tt and Leonard (1978), Scott and R osenstiel (1975),
Turkat a n d Adam s (1982).
T he Becks' theories (A. Beck, 1995; J. Beck, 1996) e m p h a siz e th e prin­
ciple that positive e m o tio n s rein force adap tive behavior.

U se o f A lt er ed States

Principles

Basic physiology has a lot to do with how' well clients understan d

and respond to various soft co u n te rin g tech n iqu es. S o m e research has
sh o w n that clients w h o are physically taut, w ith ten se m u scles and
h igh levels o f brain activity as a result o f their processin g a variety o f
stim uli sim ultaneously, are less resp onsive to this ty p e o f therapy.
Relaxation, hypnosis, and m ed itation can ease m u scle ten sio n s and
dim inish brain activity levels, en a b lin g th ese clients to n a rro w th eir
focus to the task at hand.
T here is so m e in co n clu siv e ev id en ce that A lpha states (8 -1 2 Hz) and
Theta states (4 -7 Hz) im p rov e clients' cap acity to a b s o r b in form ation
b eca u se clients are ab le to receive inputs uncritically an d w ith few er
co m p e tin g stim uli (G olem an, 1977; Grof, 1975, 1980). O u r ow n ex p e ri­
en ce suggests th at in v o k in g altered m e n ta l states is m e rely a n a d ju n ct
tech n iq u e; p e rm a n e n t or lasting ch an g es are seld om effected so lely b y
this m eth o d . This particular a d ju n ct w orks b est in su p p le m e n tin g
co n d itio n in g and p erceptual shifting tech niqu es, b u t is less effective
with o th e r procedures.
Soft c o u n te rin g uses th e follow ing m e th o d s to p ro d u c e relaxed
states.

1. B iofeedback (Carlson & Seifert, 1994).

2. T he client b reath es from th e diap h ragm an d in h ales slow ly th ro u g h
the nose, hold s his o r her breath, an d th e n ex h ales a little air at a
time. Yawning and stretch ing a c c o m p a n y in g slow r h y th m ic b r e a t h -
ing g e n erate add ition al results.
Countering Techniques: Soft_____ ..__ _____________________________________________.. 157
/

3. T h e c o u n s e lo r m ay play n a tu re tapes to indu ce relaxation. These

ta p es are recordings o f the natural sou n d s o f an ocean, a cou n try
stream , m ead ow s, an d o th e r e n v iro n m e n ta l sonances. (M any record
stores carry these tapes.)
4. Separately, o r a lo n g with the nature tapes, therapists can read en v i­
r o n m e n ta l scripts th a t d e scrib e the sen sations o f b ein g in a natural
setting such as at a b e a c h o r in a m o u n ta in cabin. (Kroger and
Fezler 11976] h av e so m e excellent scripts.)
5. Relaxation can b e h eig h ten ed if the therapist repeats phrases like,
"M y legs are getting h e a v y and warm . 1 am calm and relaxed. All
m y m u scles are loose, limp, and slack." Th ese c o m m e n ts will pro­
d u c e a m editative state if they are repeated for 20 minutes.
6. Stand ard relaxation in stru ction s (Jacobson, 1974; Sutcliffe, 1994).
7. Stand ard h y p n o tic ind u ctions (Clark & Jackson, 1983; Udolf, 1992).
8. W h ite Noise.
9. A coustic w ave sounds.

U se o f R ed u ced B ra in -w a v e S tates
Relaxed states can b e used with all CRT techniques. T h ey are most
effective w ith th e following:

1. U n m a sk in g th e co re irrational beliefs co n n ected to em o tio n al prob ­

lems. In a relaxed state clients often focus b etter on their au tom atic
thou ghts.
2. R einforcing clients' positive, cognitive changes.
3. G iving clients th e necessary distance to gau ge their beliefs o b je c ­
tively.
4. T h rou gh m e m o ry regression, en a b lin g clients to identify th e histor­
ical roots o f co re beliefs.
5. Im p ro v in g th e effectiveness o f m a n y o f the tech n iq u es presented in
this b o o k , specifically, all soft c o u n te rin g tech n iqu es— relaxed
cou n terin g , anticatastrop h ic practice, cop in g statem ents, extinction;
perceptual shifting tech n iq u es— cogn itive focusing, transposing,
im ages, bridging; a n d historical a n d cultural resynthesizing.

C om m en ts
O u r use o f Theta o r A lpha states show s contrad ictory results. We
ha v e fo u n d the learning o f cognitive m e th o d s to b e state-d ep en d en t.
If client's p rob lem s o c c u r in o n e state, then accessing that state to
ch a n g e co g n itio n s seem s practical. T he creation ol Alpha o r Theta
158 T u t N ew H a n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

states has d im in ish ed effic ien c y W ith certain clients th e y can b e h elp ­
ful, but w e d o n o t clinically su p p ort the h o o p la and ex aggerated
claim s for the curative effects o f these states. .The rea d er sh o u ld b e
aw are o f the distinction b etw een relaxation, w h ich has b e e n p ositiv ely
d em on strated to help clients, and A lpha a n d T h eta altered states,
w hich h av e not. T hey are correlated b u t n ot n ecessarily cau sally
related (see Beyerstein, 1985).

F u rther In fo r m a tio n
G o o d practical b o o k s on b io fee d b a ck use a re b y Sch w artz (1975,
1995) as well as Carlson an d Seifert (1994). For critiques see Ste in er and
Dince (1981).
I h e b attle b etw e en th e p ro p o n en ts a n d o p p o n e n ts o f altered states
rages on. O n th e p ro side are b o o k s w ritten m ostly for th e la y p u blic
(see Brown, 1974; Steam, 1976; Zaffuto, 1974). A gainst are m o r e te c h n i­
cal works (see Beatty & Legewie, 1977; Beyerstein, 1985; O rn e & P aske-
witz, 1975; Plotkin, 1979; Simkins, 1982).
The m ost fam o u s therapist u sing altered states is M ilton Erickson
(see Erickson & Rossi, 1981; Havens, 1985; Lankton, 1990; L an k ton &
Lankton, 1983; Rossi, 1980; Rossi & Ryan, 1985).
O th er g o o d b o o k s o n clinical h yp n osis are R h u e (1995), B a n d le r and
G rinder (1996), Lynn an d Kirsch (1996), a n d U d o lf (1992).
 SIX

Countering Techniques:
Objective

M ANY C O U N T E R IN G t ec h n iq u e s em p lo y hard or soft levels o f e m o ­

tional arou sal in ord er to shift irrational beliefs, b u t som etim es a cool,
n o n e m o tio n a l style is m o re effective in ch an gin g thoughts. This is
b e c a u s e an ob jective, im p erson al consid eration o f the client's beliefs
c an defu se biased em otio n s, w h ile soft o r hard cou n terin g may so m e­
tim es help c o n trib u te to th e bias.
T h e o b je ctiv e c o u n te r in g te c h n iq u e requires the therapist to pres­
e n t a logical, n o n e m o tio n a l argum ent, then persuad e th e client to
m od el th e therapist's style. Both client and c o u n se lo r analyze the
client's beliefs cold ly and im personally, as if they were using a m ath ­
em atica l formula.
O b je c tiv e c o u n te rin g states that the client's beliefs can b e changed
if the therapist h elp s a c cu m u la te m ore logic against a thou gh t th an
th e client has in su p p ort o f it; w h en the logical ev id en ce tips the
scales, th e b e lie f will shift. This view contrasts with th e o p in io n that
the e m o tio n a l intensity or h ab itu a l strength o f a c o u n te r is m ore
essential t h a n th e logic b e h in d it. T h rou gh ex p erien ce th e therapists
will learn w h ich beliefs can b e best m odified with soft counters, w hich
with hard cou nters, and w h ich with o b je ctiv e counters.
We h av e found th at an o b je ctiv e c o u n te r is m ost helpful for the
very resistant, defen sive client, as this approach is unlikely to trigger
strong e m o tio n a l reactions, th o u g h so m e clients d o b en efit from the
w arm th, em pathy, a n d positive carin g o f the therapist (Rogers, 1951,
1959). Depressed clients in particular m ay need a soft em o tio n al
a p p roach to grow their counters, w h ile p a n ic attack patients often
b e n e fit from th e attacking ap p roach o f hard countering.
1 6 0 ---- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - -- - -- - - -- - - I lJE J^ E W iiANDlQQK.Of COGNITIVE Thf.RAPY TFn-INlOllFC

An o b je ctiv e analysis o f clients' beliefs is a clean a n d elegan t

a p p roach to therapy. O u r exp erien ce, however, sh ow s th at m a n y
clients do not h o n o r logic as m u c h as th eir therapists do. For these
clients, o th e r ap p ro ach e s are n ee d e d to rep lace o r su p p le m e n t o b je c ­
tive countering.
T h e follow ing are s o m e key principles u n d erly in g variou s typ es o f
o b je ctiv e countering.

1. Have the client identify th e m a jo r co re beliefs u n d erly in g n eg ativ e

em otions.
2. Help the client dissect each b e lie f into its b asic logical c o m p o n e n ts.
Scru p u lou sly avoid su b je c tiv e ju d g m e n ts a b o u t th e b e lie f a n d its
c o m p o n e n t parts.
3. W ith the client's help, e x a m in e each b e lie f in term s o f th e principles
o f inductive and deductive logic. Decide w ith th e client w h e th e r or
n ot th e b e lie f is logical.
4. If th e client ju d ges a b e lie f to b e false, h av e th em w rite d o w n all the
logical reasons for th e rejection.
5. Tell the client to recall these reasons for rejection w h e n e v e r th e false
b e lie f recurs until it no lon g er reappears.

W e use th e in stru ctions o n the h a n d o u t to in tro d u c e clients to

o b je ctiv e countering.

E x a m p le o f A nalysis
T h e idea th a t th e re are intrinsically different classes o f p e o p le is o n e
core b e lie f that is not fou n d ed in th e factual an d can th erefo re b e
w eaken ed b y o b je ctiv e discussion. C lass-co n scio u sn ess c a u ses so m e
clients to feel depressed and a n x io u s if th ey b e lie v e th eir parents w ere
low-class. Despite th eir ow n ach iev e m en ts (m a n y are h igh ly su ccess­
ful), th ese clients still believe, a lm o st existentially, that at th e ir co re
they lack a b asic w o rth b ec a u se th e y c o m e fro m a p o o r back grou n d .
T h ese clients co n sta n tly fear b e in g exposed. T hey ju d g e th eir ob v iou s
talents and successes as part o f a facade th ey hold up to fool society
a n d th e y gu ard against situ atio ns w h ere o th ers will "see th o u g h " their
m asks and discover w h o th ey "really" are.
O th er clients w orry a b o u t th eir class in a different way. T h ese clients
c o m e from u p p er-class families b u t b e lie v e they lack certain ad m ired
t aracteristics ev id en t a m o n g low er-class individuals. T h e y m ay
b e h e v e th a t low er-class p e o p le h a v e an en e rg y o r life fo rce th a t m a k es
th e m strong a n d b etter a b le tb h a n d le th e p ra g m atic p ro b le m s o f liv -
Countering Techniques: Objective 161
/

HANDOUT: O BJEC TIV E COUNTERING

W e are surrounded by an outside reality. It impinges on all of our

senses, our bodies, and our brains. W e are born in it, live in it, and
die in it. W e don’t see this outside reality directly; w e interpret it
through our brains. Many times our interpretations are clean and
clear and therefore w e feel real pain, real sadness, and real fear, but
these are offset because w e can also feel real joy, happiness, and con­
tentment.
Many of us had a less convoluted perception of the reality around
us w hen w e were very young, w hen things seemed more clear and
sharp. But as w e got older w e started to lose the clarity of our experi­
ences, and the outside world started looking murky. W e grew more
and more distant from the external reality as our brains started devel­
oping imaginary systems that blocked our views and distorted our
more natural feelings. Others' views, such as those of our parents or
our culture, started to impinge and distort our view of this world.
Some of us lost the view altogether.
W here once only real pain could cause us unhappiness, now
abstractions and cognitive fantasies cause pain. W here once a
stubbed toe could cause us to cry, n o w hurt feelings can bring tears.
W here once the pain was removed the minute the stimulus was taken
away, n ow the pain continues for weeks, months, or even years after
the stimulus has disappeared. W here once w e would seek our great­
est jo y in clean and clear feelings, now w e throw aw ay tangible jo y
and pleasure for metaphysical abstractions. The abstractions give us
no substance, no warmth, and no closeness because they are empty
illusions, counterfeit pleasures. W e often ignore the priceless wealth
of our more direct experience for twisted notions w e learned to
develop of the world.
O ur best chance for true happiness is to return again to this out­
side reality, and the best w a y w e can do this is by evaporating as
many illusions as w e can and seeing the world more clearly again. So
let's take a look at your thoughts and see w hat is factual and w hat is
make-believe.
162 T u t N ew H a n d bo o k o i: C o g n it iv e T h e r a p y T e c h n iq u e s

ing. M ale clients often feel that th ey lack th e m a scu lin e p o w er and
cou ra g e o f their low er-class co u n te rp arts and th in k o f them selv es as
wim ps or dandies.
After th e client is sh o w n h ow to view th o u g h ts m o re objectively,
(he abstraction cau sin g th e particular p rob lem is identified and a n a ­
lyzed. In th e follow ing sch em a, th e ab straction o f class is dissected.

D efin ition s o f Class

Sy n o n y m s: breed, blood, character, genus, level, stratum , position,
rank ancestry, lineage, stock, pedigree, descent, birth, aristocracy / com ­
moner, royalty.

A ssu m p tio n s T h at L og ically U n d erlie th e C lien t's C o n cep t

1. Each individual possesses a n o n p h y sical class imprint.
2. This im p rint is s o m e h o w passed o n th ro u g h genes.
5. It is im m utable.
4. Different qualities o f w orth (high, m ediu m , o r low) intrinsically bind
them selves to this n on p h y sical h ered itary aspect called class.
5. This q u ality o f w o rth is also im m u tab le.
6. People k n o w th eir class and their q u a lity in tu itiv ely
7. Everyone is o f th e s a m e class as th eir parents, g ran d p aren ts, and
great-gran d p arents, ad infinitum .
8. People's children, grand ch ild ren, etc., are o f th e s a m e class and
quality as th ey are.
9. If p eople a p p e ar to b e o f a different class o r q u a lity than their lin­
eage, this is a facade. T hey are fakes, foolin g society, a n d o th ers will
find them o u t s o o n e r o r later. W h e n th ey a re put to th e test, they
will always sh ow th e ir true class.

E v a lu a tio n o f C on cep t
As a sociological concept class can b e a useful ab straction (Davis &
M oore, 1945; W arn er & Lunt, 1975), b u t th e term is b a n k ru p t w h en
people apply it to their ow n w orthiness. It assu m es a q u a lity th at d o e s -
n t exist: intrinsic classness. It is th e concept that each p e rso n has a
basic inherited ranking o f w o rth th a t is in d e p en d en t o f acco m p lish ­
m ents and can never b e changed. It assu m es an a lm ost spiritual ra n k ­
ing o f one's social soul.

Logical C ou n ters
1. There is no ev id en ce— an<j no m e th o d o f finding e v id e n ce — for the
ex isten ce o f a n o n p h y sical a spect o f a person called class.
Countering Techniques: Objective 163

2. How can a n o n p h y sic a l e le m e n t b e inherited?

3. Even if w e su p p osed that such an elem en t exists th ere is no m eth od
throu g h w h ich an im m u ta b le quality o f worth could b e attached to
it. W orth is a purely su b jectiv e ju d g m en t in th e eyes o f the beholder,
a n d not intrinsic to w h a t is b ein g observed.
4. W h a t particular physical, m ental, psychological, spiritual, o r m ete­
o rolog ical elem en t inside o f p e o p le allows them to intuitively know
th eir class?
5. Except w hen used in sociolog ical theory, the co n ce p t o f class is just
an arb itrary abstraction. It is im posed o n so m e p eople by others
a n d has n o m e a n in g except insofar as it reveals the feelings o f o n e
p erson for another.

C om m en t
W e do not get involved in a m etap h ysical d e b a te with o u r clients
a b o u t the virtues o f Kant's, Berkeley's, or Locke's views o f o n to lo g y or
o b je ctiv e reality. W e recognize th e su b jectiv ity o f all view's. But w e do
accept that all clients' beliefs o f them selves or th e outside world are
n ot o f eq u al utility

F u rther In fo r m a tio n
T he im p o rta n c e o f o b je ctiv e self-appraisal is m e n tio n ed b y Nisbett
and Ross (1980). O b jectiv ity is also o n e o f th e m a jo r m e th o d s used in
A b ra h a m Low's will therapy a n d th e lay organ ization he started for
ex -h o sp ita liz ed patients— Recover)' Inc. (Low, 1952).
Virtually all cogn itiv e ap p roach es teach clients to ob serv e th em ­
selves and th eir e n v ir o n m e n ts m ore o b je ctiv e ly (Bandura, 1997; A.
Beck, 1993; J. Beck, 1996; Ellis, 1988a, 1995, 1996; Lazarus, 1995;
M e ic h e n b a u m , 1994). C onstructivist therapists em p hasize that the
a d ap tab ility or usefulness o f a b e lie f is m ore im p o rtan t th an its corre­
s p o n d e n c e to so m e su pposed o b je ctiv e reality (M ahoney, 1979, 1988,
1991, 1993a, 1993b, 1994).

A l t e r n a t iv e In t e r p r e t a t io n

Principles

T he rule o f prim acy is an im p o rtan t principle in all o f psychology.

It m e a n s that p eople pay m o re atten tion to their first im pressions o f
164 T he N ew Han d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

ev en ts than to later ones. T h ese primal im p ressions can b e o f a n y ­

thing: o u r first plane ride, th e first tim e w e left h o m e , o u r first r o m a n ­
tic kiss.
But people's first in terpretations o f ev en ts are u su ally not th e best.
M a n y clients im pulsively intuit th e m e a n in g o f a giv en e v e n t an d then
stick to this initial interpretation, assu m in g that it m u st b e correct.
Later ju d gm en ts, th o u g h often m o re ob jective, o n ly rarely se em to
im plant th em selves as solidly as th e first ones. For ex am p le, s o m e p e o ­
ple c o n tin u e to b eliev e th at a n x iety causes psychosis o r th a t ten sio n
in th e pectoral m uscles indicates a heart attack sim p ly b e c a u s e th ey
had th ese th ou g h ts first. O n c e im planted, th ese ideas can b e v e ry dif­
ficult to change.
It is an u n fortu n ate truth that th e earliest in terpretation o f an ev en t
is often th e worst, so clients with m isguided ideas n ee d to b e taught
this concept. T h ey m ust learn to su spen d th eir initial ju d g m e n t until
th ey can ob tain m o re in fo rm atio n and p erceive situ atio ns m o re a c c u ­
rately.

M eth o d
1. Have th e client keep a w ritten record o f th e w orst e m o tio n s th ey
e x p e rie n ce du ring a o n e -w e e k period, n o tin g in a s e n te n c e o r tw o
th e activating ev en t (situation) and th e first in terp retation o f this
ev ent (belief).
2. For the next w eek have th e client c o n tin u e w ith th e sa m e exercise
b u t h av e him crea te at least four m o re in terp retation s for each
event. Each interpretation sh ou ld b e different from th e first, but
eq u ally plausible.
3. At th e next session h e lp th e client d ecid e w h ich o f th e fo u r inter­
pretations has th e m ost e v id e n ce o b je ctiv e ly su p p o rtin g it. Be sure
to use logic rath er than su b je c tiv e im pressions.
4. Instruct th e client to c o n tin u e to find a lternative in terp retation s, to
put first ju d g m en ts in a b e y a n c e and to m a k e a d ecision a b o u t the
correct interpretation o n ly w h en tim e and d istan ce lend th e neces­
sary objectivity. C o n tin u e this p roced u re fo r at least a m o n th until
the client can d o it autom atically.

E x a m p les
S itu atio n 1
A single, 2 5 -y e a r -o ld w o m a n just b r o k e up with her boyfriend.
Countering Techniques: Objective 165
/

F irst In te rp re ta tio n
T h ere is so m e th in g w ro n g with me. I am inadequ ate, and I'll probably
n e v e r d ev elo p a lasting relationship with a man.

A lte rn a tiv e In te rp re ta tio n s

1. I h av e n 't m et th e right man.
2. 1 don 't w a n t to give up m y freed om right now.
3. M y b o y frie n d and 1 didn't h av e the right ch em istry together.
4. M y boyfrien d was afraid to c o m m it to m e o r to the relationship.

S itu a tio n 2
After a y e a r o f takin g tranqu ilizers th e client d iscontinu es them. The
n ex t d ay h e feels a little anxious.

F irst In te rp re ta tio n
See, I k n e w it. I n eed ed th e pills to keep m e from getting anxious;
w ith o u t th em I'll crack up.

A lte rn a tiv e In te rp re ta tio n s

1. I'm a n x io u s b e c a u s e I don't have m y crutch anym ore. M y rabbit's
foot has b e e n taken away.
2. I was a n x io u s b efo re I stopped taking the pills, so so m eth in g else is
p ro b a b ly causing th e tension.
3. I h av e b e e n a n x io u s a th o u san d tim es with or w ith ou t th e pills. It
o n ly lasts fo r an h o u r o r so, then goes away. So will this.
4. Not h a v in g the ch em icals in m y b o d y m a k es m e feel different— n ot
w o rse or better, b u t different. I have b e e n calling this different feel­
ing "anxiety," b e c a u s e I interpret all different feelings as som eth in g
scary, b u t I could ju st as well call this feeling "unfam iliar" It is not
really dangerous.

S itu atio n 3
T h e client's h u sb a n d said sh e had fat legs.

F irst In te rp re ta tio n
M y legs are grotesque. I'm deform ed. I feel like I shou ldn't w ear short
p an ts b e c a u s e ev ery o n e will see them . Nature gav e m e a raw deal.

A lte rn a tiv e In te rp re ta tio n s

1. He's an idiot!
2. He was angry with m e for not havin g d in n er ready. He know s I'm
166 T u t N ew H an d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

sensitive a b o u t m y w eight a n d was trying to hurt me.

3. He is g o in g th rou g h his midlife crisis a n d w an ts m e to lo o k like 1 8 -
y e a r-o ld so th at he'll feel younger.
4. He has fat legs a n d he's projecting.

S itu atio n 4
T he client develo ped a g o ra p h o b ia 6 years ago. S h e still has panic
attacks despite fou r m o n th s o f co u n selin g w ith tw o therapists.

First In te rp re ta tio n
I'm crazy! I'll always b e afraid to g o out, and if tw o profession al th er­
apists can 't help m e then n o o n e can.

A lte rn a tiv e In te rp re ta tio n s

1. M y therapists were n o good.
2. The tech n iqu es th ey used w eren't ap p rop riate for m y problem .
3. I didn't give th e th erap y e n o u g h time.
4. It takes m o re th a n four m o n th s to get o v e r a g o rap h obia.
5. I didn't w ork at it.

C om m en t
For this tech n iq u e to b e effective, th e accu racy o f th e altern ative
interpretations is not crucial. W h at is essential is for th e clien t to real­
ize that alternative in terpretations are p ossib le and th a t first e x p la n a ­
tions are not m ag ically true sim p ly b e c a u s e th ey 're first. H aving
alternative ways o f an alyzin g ev en ts helps clients to w eak en th e cer­
tainty o f th e first interpretation an d m a k es it likely th at th ey will c o n ­
sider others a n d u ltim ately arrive at o n e that is less dam aging.

F u rther In fo r m a tio n
N um erous studies in social psychology su p p ort th e im p o rta n c e o f
prim acy o f su b jects' beliefs (see Fishbein & Ajzen, 1975; H ovland &
Janis, 1959; M iller & C am pbell, 1959; and Petty & C acioppo, 1981). A
related c o n ce p t is the "p rim acy hypothesis," w h ic h m e an s th a t a
client's primal cogn ition s m a y b e so pow erful th at th ey take o v er
o th e r processes— em o tio n al, cognitive, and b e h a v io ra l (Haaga, Dyck,
& Ernst, 1991; Beck, 1996).
Countering Techniques: Objective __ __ _ __ _ __ __ __ ___ ______ 157

R a t io n a l B e l ie f s

Principles

Like m a n y th e ra p e u tic m ethods, c o u n te rin g irrational beliefs cre­

ates o n e p rob lem w h ile solv ing another. Successful c o u n te rin g w eak­
en s an irrational th ou ght, but it also forces the client to focus on it.
Focu sing o n th e irrational th o u g h t produces th e negative em otion , so
c ou n terin g, in effect, w orks b ack w ard to rem o v e th e negative em otio n
th at the process o f c o u n te rin g has just created. C ou ntering m u st work
against b o th th e th ou g h t and th e em o tio n it elicits. This requires an
e s p e c ia lly s tr o n g c o u n t e r because n e g a tiv e e m o tio n s ten d to
stren g th en irrational beliefs.
A m o r e useful typ e o f c o u n te rin g is to have the client avoid th in k­
ing th e irrational th ou ght, thus avoiding the need to w ork against the
negative e m o tio n that it elicits. T he r a tio n a l-b e lie f tech n iq u e does just
this. T h e client im agines the realistic b e lie f im m ediately after b ein g
e x p o sed to th e e n v iro n m e n ta l triggers. W ith this approach the client
doesn't argu e against an irrational th o u g h t but instead concen trates
o n th in k in g rationally.

M eth od
1. M a k e a list o f the situations in w hich the client has gotten upset.
T h ey ca n b e specific situations from th e past o r present, o r general
life situ atio ns th e client is likely to face.
2. Prepare ration al beliefs or self-statem ents th at th e client can use in
th ese situations. T hese beliefs shou ld exaggerate neither th e posi­
tive n o r n eg ativ e features o f the situations but shou ld b e founded
on an o b je c tiv e view o f w h at is occurring. Sp end so m e tim e find­
ing th e m ost sen sib le interpretation o f the situation.
3. Record the trigger to each situation o n o n e side o f a 5 " -b y -7 " index
card. O n th e o th e r side w rite a co m p le te description o f the rational
perception th e client is trying to achieve.
4. Several tim es a day for at least 6 weeks, the client shou ld im agine
b e in g in the situ ation until it is clearly in mind.
5. W h e n this visualization b e c o m e s clea r the client shou ld picture
th in k in g th e rational b e lie f until it to o b e c o m e s clear.
6. Clients shou ld practice th e exercise until they reflexively perceive
th e rational b e lie f w h e n e v e r they picture th e event.
7. If in terv en in g irrational th ou g h ts en te r the clients' th in kin g they
 T h e N ew Ha n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

shou ld im m ed iately use "th o u g h t stopp ing" (Wolpe, 1969) an d try

o n c e again to use th e rational belief.

E x a m p le
Following are so m e ex am p le s o f c o m m o n situ atio n s and th e
rational beliefs th a t m a y b e used in them .

Situation: afraid o f m e e tin g strangers

Rational Belief: I have an op p o rtu n ity to m eet new' and interesting p e o ­
ple.

Situation: guilty a b o u t sexual dream s

R ational Belief: Sexual d ream s can b e fun.

Situation: m akes a m istake

R ational Belief: N o w 1 h av e a c h a n ce to learn s o m e th in g new.

Situation: rejected by a friend

R ational Belief: That's u n fo rtu n ate b u t n o t catastrophic.

Situation: treated unfairly

R ational Belief: 1 could insist on fair treatm ent.

Situation: fear o f public speaking

R ational Belief: 1 h av e an o p p o rtu n ity to sh o w o ff and tell o th ers w h a t I
think.

Situation: anxiou s
Rational Belief: A nxiety is u npleasant, b u t n ot d angerou s.

Situation: feels inferior

R ational Belief: In so m e things, I am. In others, I'm not.

Situation: scared
Rational Belief: Fear is ju st ch em icals m y b o d y creates.

Situation: criticized b y others

R ational Belief: If th ey are right, I h av e learn ed so m e th in g ; if w rong, I
can ignore it.

C om m en t
R ational beliefs are not necessarily th e m ost positive p ercep tio n s o f
situ atio ns— th ey are th e m ost realistic. In m ost cases th e therapist
needs to investigate the situ atio ns m e tic u lo u sly to d e te rm in e th e m ost
rational p o in t o f view.
 Countering Techniques: Objective
/ 169

F u rther In fo r m a tio n
M a n y social psychological research studies support the view that
a ttitu d e c h a n g e is m o re likely to o c cu r if su b jects h aven't com m itted
th em selv e s to a prior belief. See Brehrn, 1966; Brehm , Snres, Sensenig,
& Sh a b a n , 1966.
Nowadays, rational" is a loaded word. For so m e theorists it implies
an a b stra ct assu m p tio n that there is a n o b je ctiv e reality existing inde­
p e n d en tly and ou tsid e o f the h u m a n fram e o f reference (Mahoney,
1994; Neimeyer, M ah oney, & M urphy, 1996). Such an assu m p tion is
m e ta p h y sica l; its tru th or falseness is not a m e n a b le to em pirical m eans
(Ayer, 1952). Even Ellis presently views ration al em o tiv e th erap y (newly
n a m e d rational e m o tiv e b e h a v io r therapy since 1993) in a m o re re la -
tivistic, co n stru ctio n istic fashion (Ellis, 1988b; M cG inn, 1997). But there
is a lesser m e a n in g for "rational." It is th e rational o f everyday experi­
e n c e and can b e d eterm in ed b y the u su al m e a n s w e all em p lo y (see
th e logical analysis sectio n in this chapter).

U t il it a r ia n Co u n ters

Principles

W h ile s o m e types o f o b je ctiv e cou nters argu e against th e ration al­

ity o f a client's b e lie f and aim at correcting the logical fallacies the
clien t m a y b e em ploying, th e re is a totally different typ e o f objective
c o u n te r in w h ich the therapist d o esn 't e x a m in e the thought's truth­
fulness b u t rath er w h e th e r it is useful o r not useful. W h ile there is
n o th in g so useful to a client as the truth, it is qu ite possible for a client
to focus o n so m eth in g that is true b u t not particularly useful. For
exam p le, it is logically true that w e will all die someday, b u t it is not
useful for clients to c o n ce n tra te o n this th ou g h t every w aking m o m en t
o f th eir lives.
This p ragm atic a p p ro ach to c o u n te rin g can significantly help the
client w h o th in ks ration al b u t useless thoughts. Utilitarian cou nters
h elp clients to e x a m in e the pragm atism o f beliefs rather th a n sim ply
th eir validity.

M eth o d
1. Prepare a list o f the client's irrational thoughts.
2. Prepare a list o f situ atio ns w h e re th e th ou ghts typically occur.
5. Help th e clien t select a specific b eh a v io ra l goal to achieve in each
situation. H ave th em ask them selves, "W hat d o I w ant to a c c o m -
170 T h e ..N e w . H a n d b o o k of C o g n h l v e T h e r a p y T e c h n iq u e s

plish now?" For exam p le, you m ig h t d ev elo p goals for the clien t to
respond assertively to u nfair criticism, o r to ad m it o p e n ly to m is­
takes, etc.
4. Have the client ask for each th o u g h t, "D oes this th o u g h t h elp m e
reach m y goal or not?"
5. Ign oring w h e th e r th e th o u g h t is true o r not, h elp clients find self­
statem ents that will b e m o re useful in h elp in g th em reach their
goals.
6. Tell th e client to substitute the p ragm atic b e lie f for th e im p ractical
o n e each tim e the o p p o rtu n ity arises.
7. Help the client w ork th ro u g h a n entire h ierarch y o f situ ations, s u b ­
stituting useful th ou g h ts for im practical ones.

E x a m p le
Impractical Belief: Sh e rejected m e b e c a u s e I a m b asically an inferior
male.
G oal: To b e less likely to b e rejected in th e future.
Useful Belief: Sh e rejected m e b e c a u s e I acted in w ays sh e didn't like (not
calling h e r often, n o t c o m m ittin g to her). Since o th e r w o m e n h av e also
rejected these b eh av io rs, I’ll need to c h a n g e th e m if I w a n t to stop
b e in g rejected.

Impractical Belief: I m u st co n tro l all m y feelings to b e happy.

Goal: To b e happy.
Useful Belief: Trying to ov e rco n tro l causes u n h ap p in ess. W h e n I d o feel
b ad I'll try to u n d ersta n d th e causes o f th e e m o tio n a n d c h a n g e these
causes if I can, b u t I don't h av e to co n tro l m y e m o tio n a l responses.

Impractical Belief: I shou ld b e c o n sta n tly o n gu ard a b o u t a n y p oten tia l

d a n g er that m ay occur.
Goal: To protect myself.
Useful Belief: W orrying does n o th in g to protect m e. W h e n faced w ith a
situation I will first d e te r m in e 'w h e th e r it is truly d an g erou s. If it is, I
will d o so m eth in g practical to red uce th e danger, a n d if th e r e ’s n o th ­
ing I can do, I’ll try to accept it. O n c e I m a k e th e se decisions, I’ll g o on
w ith o th e r aspects o f m y life sin c e fu rth er th in k in g a b o u t it w o u ld b e
useless (Ellis & Harper, 1998).

Impractical Belief: I m u st b e the b e st in ev ery th in g I try.

G oal: A chieve excellence.
 Countering Techniques; Objective
/

Useful Belief: T h e b est way to ach ieve ex cellen ce is to c o n ce n trate my

tim e and en e rg y on th e tasks th a t I co n sid er im po rtant and to spend
little effort o n less-u sefu l activities. Trying to b e the best in everythin g
w astes m y en e rg y on lo w -p rio rity tasks and significantly reduces my
c h a n ce s o f reach in g a n y goals.

C om m en t
A w ord o f w a r n in g is needed o n utilitarian counters. Attacking the
utility o f a statem en t does n o th in g to c o u n te r an irrational b e lie f and
m a y in fact rein force it. For exam ple, it m ay b e b etter to directly argue
against th e belief, "1 am inferior to m ost o th e r people," rath er th a n to
suggest that there are useful ways to im prove yourself.

F u rther In fo r m a tio n
Pragm atists take the philosophical position that m eaning, know l­
edge, a n d truth can b e b etter defined in term s o f how th ey function
in o u r e x p e rie n ce— h ow useful they are in adju sting or resolving
p rob lem s. J o h n D ew ey is the m ost influ ential th in k e r and leading
s p o k esm a n for th e p h ilosop h y o f pragm atism (Dewey, 1886, 1920).
Jo h n Stuart Mill provides an earlier version o f this v ie w p o in t in ethics
(Mill, 1950, 1988).

D e p e r s o n a l iz in g S el f

P rinciples
D e p erso n aliza tio n — disassociating o n e s e lf from one's ow n self-
im age— is so m e tim e s considered to b e a neu rotic and even a psychotic
sy m p tom . It is a con d ition in w hich th e se lf b e c o m e s unfamiliar,
detached, o r u n r e a l (Cam eron, 1963). This condition is viewed as so
d a m a g in g that m ost m ental health professionals w ouldn't advocate
a n y te c h n iq u e that m ig h t p ossibly c o n trib u te to its em ergence, but
o u r e x p e rie n c e suggests that th ere are often advantages to en co u rag ­
ing a limited d egree o f depersonalization.
D e p erso n alization exists o n o n e ex tre m e en d o f a con tin u u m . On
th e o th e r e x tr e m e o f th at c o n tin u u m is an eq u ally dam agin g co n d i­
tion — h y p erp erson alization . Individuals w h o h y p erperson alize su b ­
jectify ev ery th in g to an excessiv e extent, seeing th em selv es as being
11
1 T he N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

th e ca u se o f ev ery th in g that h a p p e n s a ro u n d them . Too m u ch o f this

kind o f self-fo cu s can lead to serious d y sth y m ic disorders a n d to
ob sessive introspection. T he pattern o f realistic beliefs a n d b e h a v io rs
that w e characterize as "n o rm a l" falls m id w a y b e tw e e n th e se tw o
extrem es, th o u g h th e re are tim es w h en "n o rm a l" p e o p le e x p e rie n c e
sw ings e ith e r way. O u r c o n tin u u m can b e illustrated as follows:

h y p e r p e r s o n a liz a tio n --------------- n o r m a l ----------------- d e p erso n aliza tio n

H yperpersonalized clients con sisten tly m isattrib u te th e causes o f

events. T h ey ju d ge all causes as proprioceptive. W h e n th e y h a v e p ro b ­
lem s in th eir lives, th ey try to c h a n g e s o m e h y p o th esized deficiencies
in them selves rath er t h a n a ttem p tin g to m o d ify th eir en v iro n m en ts.
For exam ple, ag o rap h o b ics try to solv e a n x iety b y g a in in g m o re c o n ­
trol over them selv es rath er th a n b y trying to find th e e n v ir o n m e n ta l
triggers. O bsessive clients attrib u te great sig nificance and im p o rta n ce
to th eir ow n internal processing.
Therapists w h o find them selves co n fro n ted b y h y p erp e rso n a liz in g
clients can w o rk to con sciou sly shift th eir clients' p erspectives from
th at ex tre m e o n th e c o n tin u u m b a ck tow'ard th e d e p erso n a liz a tio n
extrem e. T h e g o a l is n ot to m ov e th em all the way, b u t it m ig h t b e nec­
essary (d epending u p o n th e intensity o f th e client's ten d en cies toward
self-b lam e) to m o v e th em even a little right o f th e "n o rm al" zone. This
w ould b e d o n e on the a ssu m p tio n th at th ey w'ill p ro b a b ly e x p e rie n c e
a certain degree o f p o stth e ra p eu tic slippage in the direction o f their
prior preoccupation.
The first step in d ep erson alization is to c h a n g e th e o v erp erso n alized
ca u se attribution. T he therapist m ust help clients lo o k at th em selv e s
from th e ou tsid e as others lo o k at them , as su b je c t to e n v ir o n m e n ta l
forces a n d not ju st as se lf-g en era tin g entities. T h e client needs to focus
o n o b serv a b le data to find cause and to avoid excessiv e in tern a l attri­
bution.

M eth o d
1. M a k e a list o f 20 negative ev en ts y o u r clients h a v e recen tly ex p e ri­
enced.
2. Record the hyp oth esized internal self-d eficien cies (beliefs cau sin g
h yp erp ersonalization) that th e clients th in k cau sed th e events.
3. Teach clients to lo o k for the causes o f th ese ev en ts ou tsid e o f t h e m -
 Countering. Techniques: Objective
173
/

selves. U se th e scientific m eth o d : lo o k for stimuli, reinforcem ents,

operants, or e n v ir o n m e n ta l co n tin g en cies that served as triggers for
th e n eg a tiv e events. Rew rite all p roprioceptive causes as external.
4. W h e n th e re are m u ltiple causes, use the law o f parsim ony— the
sim plest e x p la n a tio n shou ld b e used first— to d e term in e the most
likely one.
5. H ave clients practice keep in g a daily log o f events, su pposed inter­
nal causes, and ex tern al causes. Teach th em to see them selves and
oth ers as o b je cts su b je c t to e n v iro n m e n ta l influences.
6. O n c e th e clients h a v e learn e d not to take responsibility for these
influ ences, teach th e m th e kinds o f p ro b lem -so lv in g m etho d s that
can b e u sed to m o d ify th e env iron m en t.

E x a m p le
O n e o f th e b e st exam p les o f h y p erp erson alization is the way that
s o m e clients h o n o r th eir intuitive feelings. T hey th in k th a t th ey have
a deeply felt se n se o f truth a n d falseness that flows in a cavern so m e ­
w h ere inside their minds. T h ey h o n o r this sense as th e key to all
know ledge, as an alm ost spiritual vision o f the truth. For m a n y clients
this in tu ition tells them that th ey are bad, evil, o r to b la m e for every­
thing. It is the u ltim ate in h yp erperson alization. It places th e ju d g m en t
o f truth and falseness inside o f them a n d out o f reach o f ob jective
consideration.
But is there su ch a thing? The "in-my-heart-I-know-I'm-right" clients
claim th a t th ere is, and th a t their gut feelings are n ev er wrong, as n eg ­
ative as th ey m a y be. Is th ere a sixth sen se or an intuition for truth
th at n eeds n o research or logic?
I decided to in form ally test th e w h o le theory' with so m e o f m y
clients. I told a sa m p lin g o f them to focu s their intuition on th e next
10 p e o p le they met. T h ey w ere told to sav e their o p in io n s b y record­
ing all th eir feelings. The results show ed that later, after they got to
kn ow th e se people, th ey w e re w ro n g 6 0 % o f th e time.
W h e n w e e x a m in e d w h y th e clien ts' in tu ition s w ere w ro n g m ost
o f th e tim e, w e fo u n d o n e m a jo r r e a s o n — p e rso n a l bias. Th ou gh
m o s t o f th e clien ts w eren 't ev en aw are o f it, it p o iso n ed th eir ju d g ­
m ents, lu rkin g as a c o n d itio n e d re s p o n se activated b y certain types
o f people.
This was th e secret a b o u t clients' intuitions. The m arvelou s thing
they called intuition and d escribed as a b eau tiful sen se inside them
174 T u n N e w . H a n d bo o k op C o g n i t i v e T h e r a p y T e c h n iq u e s

that saw things so clearly, consisted o f ju st o n e th in g— prejudice. M a n y

had b e e n fed these g en era liz ation s sin ce they w ere infants. T heir intu ­
ition felt sp o n ta n e o u s and certain b e c a u s e a t its b a se w as a co n d i­
tion ed resp o n se that th eir reasoning had little access to, th a t p o p p ed
up w h e n e v e r th ey m et s o m e o n e o f a certain typ e w h o triggered it.
Clients' ju d g m en ts w ere o ften w ro n g b e c a u s e th e ir in tu itio n o n ly
du g up their preju dices a b o u t h ow p e o p le lo o k ed o r sou n d ed , o r w'hat
type o f w ork th ey did, or w h ere th ey c a m e from , o r w h a t th eir n a tio n ­
ality was.

C om m en t
T h e a b o v e is a very u n ro m a n tic v iew o f intuition, b u t it is the
ro m an tic view th a t causes h yp erp erson alization . Clients are initially
reluctant to give up h o n o rin g th eir intuition, b u t g rad u ally th ey
o b ta in th e n ecessary m otivation to shift th eir perceptions.
It is im p o rtan t for th e therapist to b e d iscrim in a tin g as to w h e n to
use this tech n iqu e. D ysthem ic clients often h yp erp erson alize. T h eir
infallible intuition tells th e m th at th e y are to b la m e fo r ev e ry th in g that
is g o in g o n arou n d them . O th e r clients could use a h eav y d o se o f per­
sonalization. T h e addict, th e sp o u se abuser, th e thief, th e d elin q u en t,
and th e v io le n t client all disassociate them selv es from th eir behavior.
They b la m e others fo r th eir acts an d d en y th eir ow n responsibility.
These clients would get w orse if th e therapist u sed th e a b o v e te c h ­
nique. T h ey need th e op p o site approach.

F u rther In fo r m a tio n
A lthou gh th e term h y p erp e rso n a liz atio n is n o t used, R ac h m a n
(1997) found that o b sessive clients attach great p erson al sig n ifican ce to
their ow n thoughts. T h ey b eliev e that th eir th ou g h ts are crucially
im portant, e x trem e ly m ean ingfu l, and very powerful.
D epersonalization and dissociation are discussed in th e c o n te x t o f
m ultiple p erson ality b y W atkins (1976, 1978) a n d W atkins a n d W atkins
(1980, 1981). Causality, b o th overly p ersonalized an d deperson alized, is
ex a m in e d b y S o b e r-A in and Kidd (1984) a n d Taylor an d Fiske (1975).
M cG in n and Young (1996) use d ep erso n a liz a tio n and d is c o n n e c tio n to
teach patients to d istan ce them selv es from their d a m a g in g sc h em a s in
sc h e m a -fo c u s e d th erapy (Young, 1992, 1994; Y oung & Rygh, 1994).
 Countering Techniques: Objective
/

P u b l ic M e a n in g s

Principles

In th e p reviou s section w e in trod u ced the concep ts o f hyp erp er­

so n a liz atio n an d depersonalization. A parallel con cept pertains to the
w ays in w h ich clients v iew events in their lives. A ny ev en t can b e said
to h av e b o t h a "private" a n d a "pu blic" m eaning.
Private m e a n in g s a rc associated w ith th e e m o tio n a l intensity that
p e o p le e x p e rie n c e w h en an ev en t is h a p p e n in g to th em ; they are su b ­
jective. P u blic m e a n in g is the w ay a n ev en t is ex p erien ced externally,
from th e o n lo o k e r s view point. I h e difference b etw een the tw o is the
sa m e as th e difference b e tw e e n o u r reaction w h en w e accidentally
strike o u r t h u m b with a h a m m e r and o u r reaction w hen w e see so m e ­
o n e else su c c u m b to the s a m e misfortune.
H elping clients learn to dep erson alize th eir beliefs is o n e way to
re m o v e th eir beliefs from the strong, e m o tio n a l c o m p o n e n ts that bias
th eir percep tions. T he success o f th e te c h n iq u e requires a great deal o f
practice o v e r an exten d ed period o f time. An alternative tech n iqu e
involves te a c h in g clients to shift from a private to a p u blic perspective
o n a n y ev en t that causes th em pain.

M eth o d
1. Teach clients to distinguish b etw een events th ey perceive and their
th o u g h ts a b o u t those events.
2. Help clicnts o b serv e ev en ts in terms o f public and private m e an ­
ings. P u b lic m e an in g s can b e perceived by h avin g clients practice
o b se rv in g th e situations from a n o th e r person's fram e o f reference.
Events m u st b e ob jectified. Rem ind clients that they already have a
p u b lic view, sin c e they h av e b e e n o b serv in g others in th ou san d s o f
situ atio ns all o f th eir lives. T he therapist helps clients transfer the
p ercep tio n s they h av e o f others to them selves.
3. To c h a n g e m ean in gs fro m private to public, clients m u st learn to
re m o v e fro m th eir p ercep tions the following: e m o tio n a l variables,
in ten se self-in trosp ection , an d certain m etap h ysical assum ptions.
O b v io u sly this c a n n o t b e d o n e completely, but to the ex ten t that
clients can ap p ro x im a te th e ir rem ov al th ey can m ore ob jectively
v ie w events.
4. After the c o n ce p t o f p u blic m e a n in g has b e e n explained, help th em
m a k e a list o f all th e m a jo r situations they have en co u n tered ; for
176 T h e N e w Handbook of Cognitive T h e r a p y T e c h n iq u e s

each ev en t h a v e th e m list th e p u b lic a n d p rivate m e a n in g .

5. Initially clients will h a v e to interpret ev en ts p u b licly after th e y h a v e
first au to m a tica lly perceived th e m privately. T h ro u g h a grad u al
sh a p in g process, clients will b e a b le to b rin g th e o b je c tiv e view
closer and clo ser to the tim e o f th e ev en t itself, u ltim ately replacing
th e personal w ith the p u b lic v ie w du rin g th e ev en t itself.

E x a m p le 1
Event: anxiety attack
Private w ean in g: I'm g o in g to die.
Public m eaning: A d ren alin e and o th e r ch em icals are p u m p in g in to m y
b lo o d stream.

Event: criticized b y a n o th er
Private m eaning: I m u st h av e d o n e s o m e th in g w rong. I am inferior.
Public m eaning: S o m e o n e disagrees w ith s o m e th in g I m a y h av e done.
T h e cause o f this disagreem en t is n ot known.

Event: failed in a business project

Private m ean ing: I'm in com p eten t, I'm a failure, and I'm c lim b in g d ow n
th e ladd er o f success.
Public m eaning: M y p lan n in g and preparation w ere ineffective.

Event: lost an argu m ent

Private m eaning: I am a weak, w ish y -w a sh y wimp.
Public m eaning: He knew m o re a b o u t th e su b je c t th a n I, a n d m a y ev en
h av e had m o re d eb atin g experience.

Event: have few friends

Private m eaning: Deep dow n inside I am b a sically u nlovab le.
Public m eaning: I don 't try to get friends an d I d o n 't treat p e o p le very
nicely.

Event: n o t g o o d at sports
Private m ean ing: I am a rotten male.
Public m eaning: I d o n 't h av e th e reflexes, training, or practice.

Event: 15 p ou n d s heav ier th a n w h en I was 17.

Private m eaning: 1 h a v e lost m y self-discipline.
Public m eaning: A 37 -y ea r-o ld w o m a n does n o t h a v e th e s a m e b o d y
m e ta b o lism as a teenager. *
Countering Techniques: Objective 177

E x a m p le 2

T h e private m e a n in g o f fear is the p erception that so m eth in g terri­

b le is a b o u t to h a p p en a n d m ust b e avoided at all costs. T h e public,
m o r e o b je c tiv e m e a n in g is that th ere m ay o r m ay not b e so m e real
d a n g e r present, a n d th a t it is n ecessary to lo o k at the situation to
d e te r m in e w h e th e r d an g er actually exists. Clients w h o need guidance
in ord er to v iew d a n g er from a p u blic rath er th a n su b jectiv e perspec­
tive will find th e follow ing five principles helpful. In general, fear is
o b je c tiv e if:

1. T h ere is a real d a n g er to th e person and real d am age could occur.

It is irrational to b e afraid o f m onsters u n d e r the bed sin ce they do
n o t exist and so m e th in g that does not exist can not hurt us. S o m e
clients are afraid o f sorcerers and witches.
2. T h e level o f th e fear is eq u al to the level o f d am ag e possible. It is
in a p p ro p ria te to feel terrified a b o u t getting a sm all splinter in your
foot, since th e fear w ould b e far greater th a n th e potential damage.
S o m e clients are terrified o f m ak in g a m in o r social indiscretion in
public.
3. T he fear is ap p rop riate to the prob ab ility o f th e d an g er occurring. If
a p e rso n is afraid o f b e in g hit b y a m e te o r the fear would b e irra­
tional b e c a u s e o f its low probability. S o m e clients are rem arkably
fearful a b o u t lo w -p ro b a b ility dangers such as plane crashes, while
totally ob liv io u s to m u ch h ig h er prob ab ility events such as au to­
m o b ile accidents.
4. T he d a n g er can b e controlled. Fear o f th e sun turning into a super­
n o v a w o u ld not b e useful sin ce the ev en t is b ey o n d h u m a n control.
M a n y clients are afraid o f having so m e kind o f hidden hereditary
disease.
5. T he fear is useful, as it would b e in a situation w h e re th e fear keeps
an individual m o re alert to an av oid ab le danger. Being alert ab o u t
havin g a "n erv o u s b rea k d o w n " doesn't in a n y way reduce the prob ­
ability o f h avin g one.

C om m en t
Few clients are ab le to m a ster this techniqu e. We are all prone to
g e ttin g stu ck in o u r private views o f ev ents w ith o u r em otio n s b u b ­
b lin g away. But clients w h o are a b le have an ex cellent tool that they
c an use to ev a p o ra te p an ic attacks, neutralize grief, o r extinguish rage.
178 T h e N e w H a m jb q q k j q e C o g n it iv e T h e r a p y T e c h n iq u e s

F u rther In fo r m a tio n
A aron Beck uses a related c o n ce p t called "distancing" (Beck, 1967,
1975, 1993; Beck, Emery, & G reen berg, 1985), w h ich p ro d u ces a sim ilar
red uction in em o tio n a l intensity.

D is p u t in g Ir r a t io n a l B e l ie f s (D IB )

Principles

D isputing irrational beliefs (DIB) is a sim p le b u t pow erful te c h n iq u e

that is often helpful to clients w h o h av e difficulty g au g in g th e truth or
falseness o f their ow n beliefs. W ith this tech n iqu e, w h ich w as d evel­
oped b y Ellis, clients are asked to articulate the th o u g h t in a n a ly z a b le
form and th e n to an sw er a series o f o p e n -e n d e d q u estio n s a b o u t that
belief.
Certain clients will n eed to b o lste r th eir o b je c tiv e -th in k in g skills
and to cling tightly to their rules o f e v id e n ce du rin g this ex ercise if it
is to b e useful. Analysis requires precise th in k in g an d a scru p u lou s
avoid an ce o f sidetracking, b o th o f w h ich are difficult to master. DIB
can b e useful for clients w h o get en tan g led w ith h ig h e r-le v e l a b strac­
tions.

M eth od
1. Instruct y o u r clients to an sw er th e follow ing q u estio n s in th e ord er
given w h en testing th eir beliefs.

a. W h a t b e lie f b o th e rs you?
b. Can you rationally su p p ort this belief?
c. W h a t ev id en ce exists for its falseness?
d. D oes a n y ev id en ce exist for its truth?
e. Realistically and objectively, w h a t is likely to h a p p en i f you th in k
this way?
f. W h a t could c o n tin u e to h a p p e n if y ou d o n 't th in k this way?

2. H ave y o u r clients practice applying this series o f q u estio n s to each

o f their beliefs. T hey can do this at h o m e b u t th e y m u st c o m e to
s u b se q u e n t sessions prepared to report o n th e results o f th eir
analyses. Em ploy o th e r cogn itiv e te c h n iq u e s in ad d ressin g and
p rob lem s that persist.
Countering Techniques: Objective 179
/

E x a m p le : T h e Story o f R ic h a r d

Richard c a m e to see m e b e c a u s e o f depression and g rie f over the

b r e a k u p o f his relationsh ip w ith his girlfriend. T h ey had b e e n lovers
for a b o u t tw o years. T he relationship had n ev er g o n e well, b u t they
had c lu n g to each o th e r sim p ly b e c a u s e they were b o th lonely. They
fou gh t w ith each o th er all th e tim e a b o u t their differences, each claim ­
ing th at the o th e r was w ron g an d shou ld chan ge. Finally they inflicted
so m u c h pain o n each o th e r that th e relationsh ip b e c a m e far m ore
aversive th a n reinforcing. At this poin t th e relationship ended.
W ith this ty p e o f depression, th e client usually believes that he
w asn't g o o d e n o u g h for his girlfriend, a n d that's w h y sh e left. On my
advice, h e used analysis to look at his belief.
1. W hat belief bothers me? I th in k I a m n ot w o rth y o f her.
2. Can you rationally support this belief? And w hat evidence exists fo r it falseness?
No. I can't su p p o rt it. M y g o o d n ess or b adness is a m u ltid im en ­
sion al thing. It is a totally su b jectiv e view o n m y part. M y co n clu ­
sion w ould b e totally d e p en d en t on w hat aspect o f h er I com pared
w ith w h a t aspect o f me. In addition, th ere would b e no way m y
"basic" w orth w h ilen ess could b e rated or com pared.
3. Does any evidence exist for its truth? There is no ev id en ce th a t I am not
w o rth y o f her. S h e does h av e so m e traits that are su perior to
m in e— sh e is m o r e so cia b le and m ore popular— b u t I think m ore
clearly an d act m o re responsibly. W e are b o th eq u ally worthy.
4. Realistically and objectively w hat is likely to happen? I will probably
s o o n e r or later forget h er a n d m eet so m e o n e m ore com patible.
5. W hat could continue to happen if I continue to think in the old way? I'll c o n ­
tin u e to feel unworthy. I'll g o o u t with o th e r w o m en feeling u n w o r­
th y an d I'll c o n tin u e to act w ithou t c o n fid e n ce so that they will be
m o re likely to reject m e m o re frequently. W h e n 1 get rejected again
I'll feel m o re a n d m ore unworthy.

F u rther In fo r m a tio n
This te c h n iq u e is a variation o f Ellis's procedure. The original can b e
studied b y e x a m in in g Ellis (1974, 1996) an d Ellis a n d W h itele y (1979).
180 T h e N ew H an dbo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

Lo g ic a l A n a l y s is

Principles

O b jectiv e c o u n te rin g uses m e th o d s from fields o th e r th an psychol­

ogy. A n u m b e r o f different disciplines are em ployed, b u t o n e o f th e
m a jo r o n es is logical analysis. T he m e th o d is based o n th e disciplines
o f epistem ology, inductive and d edu ctiv e logic, an d linguistical a n a ly ­
sis.
Certain c o m p o n e n ts o f logical analysis can b e used in c o u n s e lin g as
a m e th o d o f fighting d am agin g im agination. Since a client's d isco m ­
fort b e g in s with a th ou ght, th e therapist uses a cogn itiv e p rocess to
assess th e validity o f th a t th o u g h t and to rectify a n y e m o tio n a l p ro b ­
lem s sparked b y it.
Generally, th e process involves analyzing clients' th o u g h ts in term s
of: (a) w h a t exactly clients m e an by th eir th o u g h t; (b) w h e th e r th ey
k n o w th e right way to verify it; and (c) if they h av e g o o d e v id e n c e for
believin g it (Wilson, 1967).
Specifically, th e process o f logical analysis includes 5 steps, w ith a
variety o f tech n iqu es associated with each. T hese steps m ig h t b e st be
u nd erstoo d if they are presented in the form o f a n analogy. H ave y o u r
clients im ag in e that their th ou g h ts h av e b e e n put o n trial in a co u rt­
room . T h e client is b o th ju d g e and ju ry an d his o r h e r g o a l is to
d e term in e the guilt o r in n o c e n c e , truth or falseness, rationality o r irra­
tionality o f each belief. As in a n y o th e r c o u rtro o m , th e cogn itiv e
co u rtro o m has established proced ures for clarifying claim s a n d c o u n ­
terclaims, evaluating ev id en ce th at is b o th pro an d con, a n d arriving
at a carefully considered final verdict reg ard in g th e validity o f each
thought. T he process is as follows.

Step 1. Turning F eelings in to B e lie f A ssertion s

(Present th e C harges)
P rin cip les
T h e first th in g that h a p p e n s in a court o f law is th at th e d efen d an t
is ch arged with a specific crime. T h e ch a rg e is n o t general. T h e prose­
c u to r doesn't a n n o u n c e , "Your honor, this d e fen d an t is ch arg ed with
n o t b e in g a very n ice person." It is a detailed report, su ch as, "Mr. Sm ith
is charged w ith leaving th e site o f an au to a ccid en t o n Ju ly 10th, at
10:30 p .m . o n th e co rn e r o f 5th and M a in Street."
Countering Techniques: Objective 181
/

Clients are rarely so specific in their cogn itiv e charges against th e m ­

selves o r against the world. T h ey usually seek a therap ist for e m o ­
tio n al d iscom fort and are likely to express this discom fort in vague
term s th at d e scrib e th eir feelings rather than th e precise thou ghts that
p rov oked th em . M o st clients are u n aw are th a t u n d ern e a th m an y
ex p ressio n s o f feelings is a latent claim or assertion a b o u t th e way the
w orld is or th e way they th in k it sh ou ld be.
W h ile th e exp ression o f an e m o tio n is not true o r false in th e usual
sense, th e b e lie f u n d erly in g th e claim is. Therefore, the first task in log­
ical analysis is to discover th e latent m ean in gs b e n e a th clients' e m o ­
tional expressions.

M e th o d
1. H ave y o u r clients present a list o f their p rob lem feelings and ask
th em to state th o se feelings as com p letely as possible.
2. L oo k for th e claim or assertion u n d erly in g each expression, and
recast im peratives and value statem en ts in to em pirical and analyt­
ical sta tem en ts (statem ents w h o se truth o r falseness can b e ascer­
tained).

E x a m p le
Client's statem ent: "I am scared."
Underlying assertion: "There is so m e th in g out there that is d ang erou s and
it is useful for m e to fear it."

Client statem ent: "I h a te men."

Underlying assertion: "The m a le g e n d e r deserves to b e despised."

Client statem ent: "It's awful to feel unhappy."

Underlying assertion: "O n e o f the w orst things that can h a p p en to a
h itm a n b e in g is h a v in g an u n p leasan t feeling state."

Client statem ent: "I a m n o g o o d b ec a u se I am n ot rich."

Underlying assertion: "W orth as a h u m a n b ein g is b ased u p o n h ow m u ch
m o n e y a person has."

Client statem ent: "It sh o u ld n 't have h ap p en ed to me."

Underlying assertion: "There is a universal ord er that th e world is su p­
posed to follow. I can m a k e a legitim ate claim against the world w h en
I p erceiv e th a t this natural ord er is violated."
182 T u t N e w H an d bo o k or Co g n it iv e T h e r a p y T ec h n iq u e s

Step 2. D efining B eliefs

(W hat L a w H as B een Violated?)
P rin cip les
O n ce th e charges h av e b e e n presen ted in a c o u rtro o m , th e prose­
cu to r states w h ich particular law has b e e n violated. This is n o t a vague
citation su c h as, "Your Honor, w e d o n 't like w h a t h e did," b u t rather,
"Leaving the scen e o f a n a ccid en t is a v io latio n o f m u n ic ip a l co d e
5039."
O n c e their em o tio n s h av e b e e n stated in a n a n a ly z a b le form , the
therapist helps clients to define each claim o r assertion as so m eth in g
specific. T he langu age in th e claim is in h e re n tly an im p erfect c o m m u ­
nication. H u m an b ein g s tend to co m p lica te th e c o m m u n ic a tio n
process by resorting to v a g u e abstractions, e m o tio n a l ou tbu rsts, or
su g a r-co a ted platitudes in ord er to express th eir feelings and th e cog­
nitions that gav e rise to th o se feelings. It is th e th erap ist's jo b to help
clients d efine their claim s in as c o n c re te and specific a m a n n e r as p o s­
sible.

M eth o d
1. List the core beliefs. Have y o u r clients write a list o f their co re beliefs,
expressed in th e form o f a n a ly z a b le assertions.
2. Specify. Taking o n e assertion at a time, g o th ro u g h each im p o rta n t
word carefully. Ask the client to m a k e each w ord as specific and
c o n cre te as possible. You m a y w ish to use th e follo w ing in stru c­
tions.

W ords h av e different levels o f abstraction. To an alyze th ou g h ts

effectively w e shou ld use the m ost c o n cre te level. For instance,
"this table" (p oin tin g to a tab le n ea rb y me) is a specific thing.
O n ly o n e table in th e u niverse is "this table." But w e could say
m o re abstractly "tab le in th e ro o m "— th e re are several— or
"furniture," or b e even m o re ab stract and sa y "o b je c t in this
room." In each case w e are m o v in g from th e c o n c r e te to the
abstract. Notice w hat h a p p e n s w h e n w e reach th e "o b je c t in
this ro o m " level o f a b stractio n — it d o esn 't m e a n m u ch . For
instance, if w e asked, "True or false? Is the o b je c t in this ro o m
brow n?" w e w ould b e u n a b le to a n sw er b e c a u s e "o b ject" is to o
general. To kn ow th e color, w e m u s t kn ow w h a t specific
"object" w e are talking* about.
Countering Techniques: Objective
/

O u r th o u g h ts are like th is too. In ord er to un derstan d the

p h ra se "I n eed to b e rich to b e happy," w e h av e to know specif­
ically w h a t y o u m e a n b y "need," "rich," and "happy." If you
m e an "rich is b e in g a millionaire," w e could ju d ge w h e th e r all
m illion aires are happy, and w h e th e r the m o re m illions that
p e o p le possess, th e hap p ier they are. But if you m e a n "rich
eq u a ls not p o o r" o r "h avin g th e basic necessities o f life," ou r
ju d g m en t m ay b e co n sid era b ly different.

3. Pin down llle concqHs. Develop a series o f qu estion s that will help
clients pin dow n their concepts. For exam ple, the therapist can ques­
tion th e b e lie f "I a m inferior" b y asking, "W hat part o f you is infe­
rior? Have you always b e e n ? How do you know that you will always
rem ain inferior? Inferior com pared to w h o m ? W h en ? All the time or
ju st s o m e o f th e time? In ever)' way or in just a few ways? W h a t does
'I am,' in you r se n te n ce m ean ? W hat level o f'in fe rio r' are you talk­
ing a b o u t? Are you at th e ab solu te b o tto m or just a little bit infe­
rior? W h a t scale do you use to ju d g e you r inferiority? Is the scale
valid o r did you ju st m ake it up b ec a u se you were feeling bad?"
4. Rewrite the beliefs. After you and y o u r clients h a v e m a d e each word in
th e se n te n c e as specific as possible, rew'rite th e se n te n c e in corp o­
rating th e new definitions. For instance, o n e m ale client b elieved he
was g e n era lly inferior to o th e r males. A lth ou gh th e initial b elie f was
ab stract and vague, w e found the source, and w e w ere a b le to
d e fin e his term s. W e rew rote his se n te n ce as:

I a m less w orth w h ile as a m a le b ec a u se m y erect penis length

is V /i cen tim ete rs sh orter th a n the average pen ile length that
was cited in a b o o k I read som ew here, so m e tim e ago.
A fter lo o k in g at the rewritten se n te n ce h e said, "Well, that's
really stupid, isn't it?"

5. Practice. Have y o u r clients practice defining their sen ten ces until they
u n d erstan d th e n eed for c o n c r e te definitions.

Step 3. F inding th e M ean in g o f Concepts

(W hat Exactly Does th e L a ir Mean?)

P rin cip les

In a c o u r tr o o m th e p rosecu tor will d o co n sid erab ly m o re than just
read the statute th at th e d efen d an t has b e e n charged with. He will
take great care to ex p lain the key c o m p o n e n ts o f th e law in o rd e r to
show how it has b e e n violated. For instance, h e m ig h t e x p la in "m alice
w ith foreth o u g h t" m e a n s o r th e differen ce b e tw e e n "v o lu n ta ry " and
"in volu n tary " actions.
T h e d efin in g -b e liefs te c h n iq u e discussed a b o v e m ig h t b e m islea d ­
ing lo the e x te n t th a t it suggests th a t d efin in g clients' th o u g h ts is sim ­
ply a m atter o f relying u p o n w h a t clients believe th e defin ition sh ou ld
b e or o f lo o k in g up a particular term or p h rase in a dictionary. The
d efinin g process is usu ally m u c h h ard er th a n that. W h a t clients want
a definition to b e is o ften at odd s with p revailin g o p in io n , and even
lexicographers w h o w rite d iction aries are usu ally years b e h in d p o p u ­
lar usage in their definitions o f certain terms.
A "real man," for exam ple, could m e a n " o f or b e lo n g in g to th e sex
th a t produces sp e rm a n d is ca p a b le o f fertilizing ova" (o n e d ictionary's
definition). O r it could m ean, "a cool, tall, muscular, b ig -p en ise d , hair)',
b eer-d rin k in g , fo o tb all-w atch in g creatu re w h o can b ea t th e hell o u t o f
ev eryone" (the client's definition). W h e n d efin ing clients' beliefs, w7e
w ant to kn ow h ow th ey are using w ords and w h a t m e a n in g th e y give
to phrases, not w hat dictionaries say.
T here is a g o o d m e th o d for finding the m e a n in g b e h in d a client's
phrases. T he British p h ilo so p h er Ja m e s W ilson (1963) has d e v elo p ed a
te c h n iq u e called th e "analysis o f concepts," w h ich therapists can use to
ferret out client m eanings. It is o n e o f th e m ost useful te c h n iq u e s th er­
apists h av e in their arsenal. It consists o f im ag in in g a m o d el c a se and
c o m p a rin g it to a contrary' case.

M eth od
1. M odel Case. You and y o u r client select a n e x a m p le o f th e correct u se
o f a key co n ce p t taken directly from an an a ly z a b le assertion. The
e x am p le sh ou ld b e an ideal that virtu ally a n y o n e w ould th in k is a
valid ex a m p le o f th e concept.

Example. D ap h n ia c a m e to see m e b e c a u s e s h e w as suffering from

a pow erful guilt. S h e felt that s h e was bad, im m o ra l, a n d evil and
b elieved that sh e sh ou ld b e p u n ish ed b e c a u s e s h e h ad h u rt the
feelings o f a loved o n e o n a series o f occasions.
To d e te rm in e w h e th e r h e r b e h a v io r could correctly b e ju d ged
as "bad," I asked h er to search h e r m in d for a m od el case th at vir­
tually ev ery o n e w ould agree w as an e x a m p le o f a b ad act. S h e
recalled a new sp ap er article sh e had read. Several years earlier
th ree m e n had b e e n h u n tin g for deer. They'd had n o lu ck a n d
Countering Techniques: Objective 185
/

w e r e sitting o n a hilltop feeling bored. They noticed a n o th e r m an

w alk in g dow n a road in the valley below. T h ey had n ev er seen
h im b efore, and fo r th e sport o f it they started sh o o tin g at him.
He tried to run aw ay b u t after several tries they hit and killed
him. T he m e n th e n left th e dead m an o n th e road and w ent
h o m e for dinner. I agreed with D ap h n ia that this was an excel­
lent e x a m p le o f w h at e v e r y b o d y w ould agree is "bad" behavior.

2. Conlrai}' Model. Select an ex am p le o f a contrary' case. Pick an ideal sit­

u ation as sim ilar as possible to the first, b u t in w hich th e concept
w ould clearly (in the ju d g m en t o f m ost people) not apply. (For ex am ­
ple, w h atev er "bad" means, this case is clearly not an exam ple o f it.)

Example. (M y client and I selected th e follow ing case.) A m a n was

driving his car alon g a narrow street lined w ith large trees and
foliage. It was late at night and h e was driving carefully, b elow
th e speed limit; h e was a nondrinker. Suddenly a b o y dashed in
front o f his car from b e h in d a large bush. T h e m a n slam m ed on
his b ra k es b u t cou ld n 't stop. He hit the b o y and killed him. He
tried to h elp the b o y b u t saw that it was to o late. He called the
police and waited for th em to arrive.

5. Compare the M odel Case to the Contrar}' Case. D eterm ine what key princi­
ples w ere present in the m odel th a t were not present in th e c o n ­
trar)' case. W h at are th e similarities and differences b etw een the
tw o? List them .

Example. W h e n w e ex am in e d the c o m p o n e n ts o f the m od el case

to d e te rm in e w h y th e m en's b e h a v io r could correctly b e called
bad, w e con clu d ed :

a. T h e u n k n o w n m a n was killed (bad ev en t occurred).

b. T h e th re e m e n killed h im (they caused it).
c. T hey had no reason to kill him (unjustified).
d. T hey c h o se to kill him (intended it).
e. T hey could h av e avoided killing h im (had free choice).
f. T h ey k n e w w h a t th ey w ere doing (were aware).

W h e n w e e x a m in e d th e con trar)' case w e determ ined th e o n ly sim ­

ilarities p resent were:

a. T h e b o y was killed (bad ev en t occurred).

b. T h e driver killed h im (he caused it).
c. T h e driver had no rea so n to kill h im (unjustified).
186 Th e N e w H a n d bo o k oe Co g n it iv e T h e r a p y T e c h n iq u e s

4. To d e te rm in e w h ich principles o r c o m b in a tio n o f principles are

essential to the concep t, ta k e each rule o n e at a tim e a n d th in k o f
situations th at included all th e o th e r rules e x c e p t this on e . If th e
co n ce p t n o lon g er applies, th e n th e rule is essential.

a. For exam p le, could w e ju d g e th e h u n ters' b e h a v io r as b ad if

n o th in g bad had h a p p e n e d — if th ey had b e e n sh o o tin g at tin
cans instead o f people? No. If n o o n e was killed, in ju red , hurt, or
threatened in so m e way, w e cou ld n 't call an act bad.
b. Is the act bad if s o m e o n e w asn't the cau se o f th e oth er's d eath?
If th e m an were struck by lightning, w e w o u ld n 't b la m e th e
hunters.
c. Is th e act b ad if the h u n ters h ad a g o o d re a s o n for sh o o tin g him?
No. A p o licem a n has a right to s h o o t an attacking felon.
d. Is th e act bad if th e h u n ters h a d n 't in ten d ed it? No. As in o u r
driving exam ple, o n e reason th e driver was n ot gu ilty o f m u r­
dering th e b o y was that h e did not intend to do so.
e. Is the act b ad if it could n't have b e e n avoided? No. Im a g in e an
adult g r a b b in g a child's h a n d and m a k in g him hit his sister. The
child is not to b la m e for hitting his sister.
f. Is th e act b ad if th e person isn't aw are o f w h at h e is doin g? No.
If a psychotic veteran sh o o ts a m a n w h ile h allu cin a tin g that h e
is b ein g attacked b y his a n c ie n t enem y, h e is not to b lam e.

In o u r exam ple, all rules w ere n ecessary to call t h e act "bad." T he

w ay th a t D aphnia used the concept, a b e h a v io r is b a d i f s o m e th in g
bad h ap p en s, if it is caused b y a n o th e r person, if th e re was n o g o o d
reason for th e act, if it w as in tentional, if a person has th e freed o m
not to d o it, and if a person was aware. If ju st o n e rule is missing,
then the b e h a v io r c a n n o t b e called bad.
The driver w h o hit th e b o y c a n n o t b e resp o n sib le b e c a u s e th ree
rules w ere not present in his case that w ere p resent in th e hunters'
case: intention, freedom , and awareness. Clearly, p e o p le c a n ’t accu ­
rately call them selves bad sim p ly b e c a u s e th ey h a v e hurt a n o th e r
person w ith ou t reason. If th ey d o a n d they feel gu ilty a b o u t it, th eir
th in k in g is false. A nd th e ir irrationality is n ot ju st play for th e a c a ­
d em ic linguist; it is a life-th reatening , crucial distinction. B e cau se o f
rules d, e, and f, th e h u n ters sh ou ld b e con v icted o f m u rd er; w ith ­
ou t the rules th e driver is guilty o f n o th in g b u t an u n fo rtu n a te acci­
dent.
5. O n c e you r analysis u n cov ers the crucial rules, ap p ly th e m to the
client's ow n beliefs.
Countering Techniques: Objective 187
/

Example. M y gu ilty client found sh e could n o t accu rately call any

o f her previou s b e h a v io r bad, since at least o n e rule was always
missing. In s o m e o f th e "bad" acts sh e described, n o n e o f the
rules applied!
D aphnia's in sig h t into the illogical nature o f her thinking
e n a b le d h e r to use o th e r cognitive restructuring tech n iq u es later
in o u r counseling.

Step 4. Ju d g in g Evidence
(th e Ju ry E x a m in es th e Evidence)
P rin cip le s
In th e c o u rtro o m , th e a ttorn eys present the ev id en ce for and
against th e defendant, and th e ju ry retires to e x a m in e the evidence. In
counseling , th e client and therapist use inductive reason in g to e x a m ­
ine th e e v id e n ce for and against a belief.
A great m a n y clients h av e difficulty reason ing inductively— i.e.,
form in g gen eral h y p o th ese s and con clu sion s from specific facts. They
m ak e th eir ju d g m en ts based o n intuitive guesses rath er than o n evi­
d ence, a n d o ften th ese guesses lead to an erro n eo u s interpretation o f
events, an d this in turn creates m o re em o tio n a l turmoil. If th ese clients
are tau g h t so m e b asic principles, they can learn to stop m aking ran­
d o m assu m p tion s, thus sh ort-circu itin g th e em o tio n a l pain that these
a ssu m p tio n s so often produce.
T h ere are m a n y m e th o d s to teach ind u ctive reasoning and so m e are
q u ite com plicated, requ irin g a g o o d b a ck g ro u n d in th e p h ilosop h y o f
th e scientific m e th o d (I h av e reviewed so m e o f these in m y earlier
b o o k , M e M ullin, 1986, pp. 225-266). But in clinical practice I have
fo u n d an easier m e th o d th a t provides th e sa m e kind o f inform ation.
It is called g rap h analysis.
To un derstand g rap h analysis, co n sid er w h at the w ord "evidence"
m eans. In th e c o n te x t o f logical procedures, ev id en ce show s the asso­
ciatio n b e tw e e n tw o o r m o re things. O r to put it in scientific terms,
e v id e n c e sh ow s the correlation b e tw e e n two or m ore variables. In a
c o u r tr o o m the variables m ay b e the co m m issio n o f a crim e (such as
stealing a car), and its correlation with a particular defen d an t (a wit­
nesses saw th e d efen d an t b rea k into th e car, and th e police arrested
th e d e fen d a n t w h ile driv ing th e car).
In co u n s e lin g th e s a m e principle applies. T h e therapist and client
lo o k for correlation s b etw e en tw o o r m o re variables that m ay b e
related to th e client's sym ptom s. For exam ple, the therapist may look
188 ■Th e N e w H a n d b o o k of Co g n it iv e T h e r a p y T ec h n iq u e s

for th e asso ciation b etw e en m ed ica tio n s and m a n ic sy m p to m s, a lc o ­

hol use and sp o u se abuse, se lf-c o n c ep t a n d ach iev e m en t, o r b etw een
a client's depression and her marriage.
To collect evidence, therefore, th e clien t a n d therap ist need to lo o k
for correlations that sh o w a relationsh ip a m o n g certain v ariab les and
a client's sym ptom s. But th e p rocess is difficult. T h ere can b e an e n o r ­
m o u s n u m b e r o f factors th at could b e related to a n y sy m p tom . How
c an o n e d e te rm in e w hich variables are correlated an d w h ich a re irrel­
evant? G raphs analysis provides a w ay to o n ly a n a ly z e th o se v a ria b le
that sh ow promise.
Nowadays I use g rap h analysis with a lm ost all m y clients, u su ally
with g o o d results. This is also a v a lu a b le te c h n iq u e to teach clients,
w h o can prepare and plot th eir ow n variables.

M eth od
1. O n graph p a p e r plot a n y tw o o r m o re v ariab les th a t m a y b e im p o r­
tan t to y ou and y o u r client. (For exam p le, m a y b e y o u wish to k n o w
w h a t causes Fred's p an ic attacks. You th in k th ey could b e cau sed b y
so m eth in g in his m arriage o r his job.)
2. O n th e Y axis, chart th e intensity o f the targeted sy m p tom , em otio n ,
o r behavior. (In o u r e x a m p le you would plot the fre q u e n c y o f Fred's
p an ic attacks. S ee figure 6 .1 .)

ipanic attacks ■ ■ marital problem s w ork problems

Ja n M ar M a y Ju l S ep N ov Ja n M ar M ay Ju l Sep N ov

MONTHS

F i g u r e 6 i Fred's graph. The higher the line, the greater the intensity of the
panic attacks, marital or job problems.
Countering Techniques: Objective
/

3. O n th e X axis, record th e tim e period w h en these sy m p tom s or

b e h a v io rs occu rred . You can u se a n y tim e duration: hours, weeks,
m on ths, years, th ro u g h o u t th e life o f a client (these are called life­
tim e graphs), or th e tim e b efo re and after so m e m a jo r traum atic
event. (If Fred started his attacks 2 years ago, you would list every
m o n th for th e last 2 years.)
4. Plot o n th e s a m e g rap h any variables that you b eliev e m ay b e
related to th e sy m p tom , em otio n , or b e h a v io r you are tracking. (You
w ould plot the intensity o f Fred's problem s with his m arriage and
jo b o n the Y axis.)

Discuss w ith y o u r client th e relationships a m o n g the lines. (We would

sh ow Fred th at th e difficulties with his jo b seem unrelated to his panic
attacks. However, his m arital p rob lem s and panic attacks d o seem cor­
related. From the graph a lo n e w e can not kn ow w h ich causes which,
b u t fu rth er in q u iry w ould p ro b a b ly reveal th e connection.)
A n y client variables can b e charted o n th e graph. T he following
ex a m p le s c o m e from different clients an d sh ow th e variety o f factors
th a t can b e plotted.

E x a m p le s
Figure 6.2 suggests a negative correlation b etw e en Karen's happi­
ness and depend ency. T he m ore d ep en d en t Karen was o n others, the
less happ y s h e was. Karen was sexu ally ab used as a child and physi­
cally a b u sed b y her two husbands. O n ly w h e n sh e was free o f them
a n d in co n tro l o f her ow n life was she happy.

F ig u r e 6 .2 K a r e n 's lif e lin e g r a p h : c o r r e la t io n b e t w e e n K a r e n 's h a p p in e s s a n d

d e p e n d e n c y . T h e h ig h e r t h e lin e t h e m o r e s h e r a te d h e r life a s h a p p y o r ju d g e d
h e r r e la tio n s h ip s a s d e p e n d e n t.
190 T e e N e w H a n d bo o k o i - Co g n it iv e T h e r a p y T e c h n iq u e s

Not o n ly can g rap h s b e plotted for individu al clients, b u t th e y can

also b e created for grou ps o f clients with certain sy m p to m s. Figure 6.3
is a c o m b in e d graph correlatin g a lco h o l u se and h ap p in ess fo r 2 4 4
clients from fou r different trea tm en t facilities in th r e e countries. The
chart show s that th e average a lc o h o lic clien t in th e sa m p le did not
h av e n o ticea b ly bad ch ildhood s. T hese are averages, so s o m e clients
had positive ch ild h ood s (40%), so m e had neu tral (19%) a n d s o m e had
n egative (41Q/0). W h e n th ese clients started to drink alcohol (at th e
m ean age o f 13.9), their h ap p iness sh a rp ly declined. T he g rap h show s
an arbitrary' item at age 55 to rep resen t th o se clients w h o stop p ed
d rin king b u t th e n started again. In general, th e g ra p h show s clients'
overall happiness was in versely related to th eir a lco h o l use.
G raphs can b e used for finding th e effectiveness o f certain treat­
m e n t as well as th e causes o f certain sym ptom s. Figure 6.4 d e m o n ­
strates that lithiu m was an effective treatm en t for Alan's m a n ic
sym ptom s. After seven days o f receiving a full dosage, th e m ed ica tio n
to o k effect.
G raphs can also b e used to track th e correlation b e tw e e n cogn ition s
and b ehaviors. Figure 6.5 tracks five beliefs that affect w h e th e r psy­
ch otic patients are ab le to live successfully in the c o m m u n ity or
w h e th e r they keep retu rnin g to hospitals. T h e h ig h e r the line th e m o re
the patients accepted th e various cognitions. A sco re o f five m ean s
that they strongly b e lie v e a thou ght, and a sco re o f o n e m e a n s th ey
strongly reject th e thought. As th e g rap h show s, patients w h o were
a b le to live in the c o m m u n ity w ere m o re likely to a ccep t th a t th ey had

Happiness

>-
on
2
UJ

AGE

F ig u r e 6 .3 C om bin ed lifelin e grap h : grou p co rrelatio n b etw e e n a lco h o l use

hoi use h a PP,n ess- The h ig h er d ie line, th e g reater eith er h ap p in ess o r a lc o -
Countering Techniques; Objective 191
/

Fig u r e 6 .4 Effects of lithium on Alan's manic symptoms. A high line indi­

cated either high levels o f lithium or high manic behavior..

F ig u r e 6 .5 C o m p a r is o n o f t h e b e lie fs o f s e r io u s ly m e n t a lly ill p a t ie n t s w h o

a r e r e h o s p ita liz e d a n d th o s e w h o a r e a b le to liv e in t h e c o m m u n ity .

a m en tal illness and needed to take their m edications, w hile the hos­
pitalized grou p was m ore likely to b eliev e that they didn t have a
m e n ta l health p rob lem and that they didn't need their m edications
(see th e section o n treating seriously m en tally ill patients for m ore
in fo rm atio n a b o u t this study).

C o m m e n t
M y e x -fa th e r in law— Harry Jessup D u n h a m (1913 -1 9 93 )— show ed
m e the im p o rta n c e o f using graphs. He was an e n g in e e r for the Apollo
p rog ram for NASA, w h ich sent m e n to the m o o n in the late sixties and
 T h e . N e w H a n d bo o k o f Co g n it iv e T h e r a p y T ec h n iq u e s

early seventies. O n e d ay I was r u n n in g co rrelatio n al a n a ly ses o n m a n y

variables in ord er to find w h at m ight b e c a u s in g a client's p an ic
attacks. He w atch ed m e for a w hile, then w alked o v e r a n d suggested
that it would b e a lot easier and save a lot o f v a lu a b le calcu la tin g tim e
if I would get at least a rough idea o f w h e th e r th e variables were
related b e fo re I tried to co rrelate them . He rem in d ed m e that I could
d o that b y using graphs.
G raph analysis had b e e n o n e o f th e b asic topics co v ered in m y sta­
tistics courses, b u t I n e v e r used it in m y th era p e u tic practice. B u t NASA
en g ineers w o rk in g on A pollo used g rap h s all th e time. Mr. D u n h am
told m e th a t it would h a v e ta k en m o n th s to calcu late all o f th e p o ssi­
b le relations o f all the possible v ariab le involved in se n d in g a rocket
to the m o o n , so instead th e en g in eers draw a g rap h and o n ly an alyze
those variables th at sh ow promise.
He said that all 1 had to do was to get s o m e g rap h p a p er an d plot
the intensity o f each v a ria b le on the vertical Y axis (ordinate) and its
o c cu rre n c e over tim e o n th e horizon tal X axis (abscissa). Each variable,
m turn, could b e plotted o n th e s a m e graph. T h o se lines th a t had sim ­
ilar or exact op p o site curves w ere p ro b a b ly related a n d w o rth co rre ­
lational analysis, w h ile the others could b e discarded. T he total
n u m b e r o f likely variables was th u s red uced to a far m o re m a n a g e ­
ab le quantity.

Step 5. D ecision a n d C o m m itm en t

(the Ju ry Gives th e Verdict)
P rin cip les
The w h o le p u rp o se o f a trial is for th e ju r y to c o m e to a d ecision
a b o u t th e guilt o r in n o c e n c e o f th e defen d an t. Similarly, th e w h o le
p u rp o se o f logical analysis is for th e clien t to m a k e a d ecision a b o u t
th e truth o r falseness o f his assertion.
Clients often avoid th e final step b e c a u s e th e y are relu ctan t to m ak e
a c o m m itm e n t to c h a n g e a thought. It is easier to stay o n th e fe n ce
and c o n tin u e eq u iv ocatin g. F o r-co g n itiv e c h a n g e to ta k e p lace it is
essential that a c o m m itm e n t b e made.

M eth od
1. Tell clients th at th e y m u s t m a k e a d ecision h ere an d n o w as to
w h eth er the B is true o r false.
2. I f th e B is tru e t h e clients shou ld d o s o m e th in g to c h a n g e th e situ ­
ation, or, if it can't b e changed , th ey m u st learn to a ccep t it.
Countering Techniques: Objective 193
/

3. If th e B is false have clients c o m m it to w orking against the B in

th o u g h t and actio n no m atter h ow long it takes.
4. Have clients w rite a d ecision and a contract a b o u t what they are
g o in g to d o to c h a n g e th e thou gh t. T he p r o o f o f a c o m m itm e n t is
th e actio n taken.
5. The therapist is som etim es in a situation w h ere a client believes a
th ou g h t is true even though the cou nselor d oesn ’t think so. If the
client has g o n e through th e logical analysis process it is important
that the therapist support even u n p op u lar decisions. The client has
the right to not w o rk o n a cognition or to believe in a thought that
you may think is irrational. You can point out the results o f the
thinking, th e ultim ate consequences, b u t it is up to th e client to m ake
the decision. Even the act o f m aking a decision is therapeutic, and I
have found that clients will often change irrational ones later on.

F u rther In fo r m a tio n
Philosophy, not psychology, has th e m ost useful references for log­
ical analysis. T he b est references for taking feelings and tu rning th em
in to cogn itiv e assertions lie in Linguistic Analysis (see K lem ke, 1983;
Langacker, 1972; and esp ecially W ilson, 1967). Excellent ex am p les o f
d efin in g co n ce p ts and w ords can b e fou nd in Ayer (1952, 1984, 1988),
M u n itz (1981), Q u in e (1987), Ryle (1949, 1957, 1960), U rm son (1950), W il­
son (1967).
T h e d e fin in g -c o n c e p t ap p roach is a m od ification o f W ilson's (1963)
m e th o d o f analysis. T he read er shou ld go directly to this w ork for a
m o re c o m p r e h e n s iv e ex p la n a tio n o f th e procedure.
D escriptions o f th e theoretical co n d itio n s necessary to find causes
are included in th e gen eral w orks o f B ro w n and Ghiselli (1955), Ray
and Ravizza (1981), and Sim on (1978). T h e m e th o d o f agreem en t and
difference is c o m p le te ly exp lain ed in Mill's classic w ork (Nagel, 1950).
Ju d g in g e v id e n ce and using inductive reason ing is explained in the
classic w orks o f B ertrand Russell (1945, 1957, 1961), Alfred North
W h ite h e a d (1967), A ckerm an n (1965), an d Taylor (1963). Sim ilar discus­
sion s in cogn itiv e psychology can b e fou n d in th e works ol Bruner,
G ood n ow , and Austin (1956), H aygood and B ou rne (1965), Jo h n s o n
(1972), Popper (1959), Trabasso and Bower (1968), W atson and Jo h n s o n -
Laird (1972). M o re c o m p le x ex am p le s are can b e fou nd in th e work o f
A n d erson (1980); Teasdale discusses the in flu en ce o f sch em a tic m odes
o n logical reaso n in g (Teasdale 1993, 1996; Teasdale & Barnard, 1993).
G raph th eo ry is a m a jo r and intricate c o m p o n e n t o f m athem atics,
194 T h e N e w H an d bo o k oe Co g n it iv e T h er a py T e c h n iq u e s

c o m p u te r science, chemistry, and m a n y o th e r disciplines. But for o u r

pu rposes w e are p ro p o sin g n o th in g so involved. T h e typ e o f g ra p h in g
used in therapy can b e fou n d in a n y b e g in n in g statistic b o o k . Victo­
ria C olem an (1998) has develo p ed a m o re in volv ed lifeline gra p h in g
procedure.
D ecision and c o m m itm e n t are th e key features o f a c ce p ta n ce and
c o m m itm e n t therapy (ACT) (Hayes, Strosahl, & W ilson, 1996; Hayes &
W ilson, 1994).

Lo g ic a l Fa l l a c ie s

Principles

Logical fallacies a re u nsu b stan tiated assertions that a re often deliv­

ered with a co n v ictio n that m akes them sou n d as th o u g h th ey are
proven facts. S o m e o f these fallacies derive from clients' perceptual
distortions (e.g., overgeneralizations), o th ers from psych ological errors
(e.g., catastrophizing), w'hile still others are logical distortions (e.g., a
priori thinking). S o m etim e s fallacies result w h en p e o p le m istak e co r­
relation for causalities.
W h a tev e r their origins, fallacies can tak e on a special life o f their
ow n w h en th ey are popularized in the m edia a n d b e c o m e part o f a
n a tio n al credo. O n ce th ey have ach ieved this stature th ey hold a sp e ­
cial appeal for th o se w h o seek the approval o f o th ers by resortin g to
these c o m m o n ly held m isperceptions.
Fallacies are m ost likely to creep into th e in te ra c tio n s b e tw e e n
client and therapist d u rin g th e logical analysis process, w h en the
client is m a n ip u la tin g the ev id en ce t h a t has b e e n am assed for or
against a dam agin g belief. "Better safe t h a n sorry," o u r client m ig h t say,
q u o tin g a p o p u lar platitude, w ith o u t recognizin g that th e platitude
has n o th in g to d o with th e rules o f e v id e n ce that h e has established,
and therefore c a n n o t b e advan ced as p r o o f o f a n assertion.
The best way to teach clients a b o u t logical fallacies is b y calling their
attention to such utterances the m o m e n t that they are expressed and b y
im m ediately p ointing out how they con trib u te nothing to o u r evaluation
o f w h eth er a b e lie f is true o r false. M o re often th a n not they are merely
diversions that help clients avoid coin in g to grips w ith a lifetime's accu­
m ulation o f m istaken perceptions. Put all o f th e logical fallacies you can
assem b le on o n e side o f a scale and o n e piece o f solid ev id en ce o n the
other, an d th e scale will instantly tip in favor o f th e evidence.
Countering Techniques: Objective 195
/

M eth o d
O n c e clients recognize how essentially v acu o u s logical fallacies are,
th ey c a n b e tau g h t to avoid resorting to these linguistic diversions.
T h e b est w ay to teach th e m this is b y presenting th em with exam ples
a n d en c o u ra g in g th e m to c o u n te r ever)' fallacy th ey utter o r h ear until
they b e c o m e satiated w ith the pointlessness o f these assertions.

E x a m p le
Follow ing is a list o f c o m m o n types o f logical fallacies with their
defin ition s a n d so m e ex a m p le s o f each.

S e n sa tio n a lism
Sim ple, in n o c e n t em o tio n s that h a p p en to alm ost ev ery on e are
built up into terrible, overw helm in g, psychiatric em ergencies.

• "1 m u st b e depressed b e c a u s e I feel sad after m y vacation."

• "It's d a n g ero u s to get nervous."

O v e rg e n e ra liz a tio n
A few' instances o f a category are taken to represent the total cate­
gory.

• "I am inferior to M ik e b e c a u s e h e always beats m e in racquetball."

• "A n ybody w h o can't spell is stupid."

P e rso n a liz in g
V iew ing ra n d o m ev en ts as a personal attack on oneself.

• "I b r o k e m y leg b e c a u s e G od is p u nishing m e fo r m y past sins."

• "Th ere is a g o o d reason for ev eryth in g that h a p p en s to a person."

A n th ro p o m o rp h is m
Attributing h u m a n characteristics to in a n im ate objects.

• "The c a r refused to budge."

• "The th u n d e r b o o m e d angrily."
• "Lady lu ck was against me."

P e rm a tiz in g
M a k in g s o m e th in g tem p o ra ry into so m eth in g perm anent.
196 T i n N e w Ha n d b o o k of C o g n it iv e T h e r a p y T e c h n iq u e s

• "I am g o in g to b e scared forever."

• "I'll n ev er b e happyf

F a u lt-fin d in g
L ooking for so m e o n e (others o r self) to b la m e w h en s o m e th in g goes
wrong.

• "It's m y (or m y spouse's) fault th at the m arriage didn't last."

• "All crim inals are p rod u ced b y b ad parents."

P ath o logizin g
Calling a learned reaction a disease.

• "Anybody w h o is a n x io u s all th e tim e is really sick.

• "O veraggressiveness is a disease."

P e rfe ctio n ism

Picking the highest th eo retica lly c o n ce iv a b le stan dard for o n e s e lf
and others, even th o u g h practically n o o n e has ev er b e e n a b le to
ach ieve it, and th e n using it as th e c o m m o n m e a su re for a person's
worth.

• "I shou ld n e v e r m a k e mistakes."

• "I h av e to b e b etter th a n e v e ry b o d y else, in everything."

D ich o to m o u s T h in k in g
Judging a co n ce p t that is actu ally o n a c o n tin u u m as tw o m u tu ally
exclusive parts (also called a ll-o r -n o th in g , o r g o o d - a n d - b a d thinking).

• "Abortion is eith er right o r wrong."

• "If it's w orth doing, it's w orth d o in g well."
• In this world you are eith er a w in n e r or loser”
• "So m e m e n have it and so m e m e n don't."

"Awfulizing"
Looking for th e w orst possible o u tc o m e o f a n y event.

• "This pain in m y leg m e an s I h a v e cancer."

• "M y h u sb an d is late; h e m u st b e h avin g a n affair."
• "If I d o n 't get an A in this class, I'll n ev er get into m ed ical school."

"M u stu rb a tio n "

M ak in g "wants" in to "musls," "oughts," and "shoulds."
Countering Techniques: Objective 197
/

• "I h av e to get h e r back."

• "I n eed to b e c o m e a great actress to ev er b e happy."
• "I m u st b e sure to decide."

E n title m e n t
C laim ing an ex cep tion al privilege that doesn't exist (the p r in c e -in -
disguise syndrom e).

• "I sh o u ld n 't have to put up w ith all the petty things th ey m ak e m e

d o at work."
• "It's u nfair that I h av e to sh ow m y driver's license to cash a check."
• "W h y d o I h a v e to wait in line at the airport like ev ery on e else?"

P sy c h o lo g iz in g
Finding psych ological causes for events, w hile ignoring other
causes.

• "I b u m p e d into the table b e c a u s e I was trying to hurt myself."

• "M y sore sh o u ld e r m u st b e caused b y u n con scio u s anxiety."
• "You forgot m y n a m e b e c a u s e you 're b lock in g it."
• "You're single b e c a u s e you 're afraid o f g etting married."
• "You didn't su cceed b e c a u s e you h a v e a fear o f success."
• "You failed b e c a u s e you were trying to fail."

N o n p a rsim o n io u s R e a so n in g
C h o o sin g th e m o re c o m p le x ex p la n a tio n over th e simplest.

• "You don't like it w hen I criticize you because you had a love-hate rela­
tionship with you r father, and all m en represent father figures to you."
• "You are ju st transferring y o u r infantile repressed hostility o n to me."
• "People b e c o m e psychotic b e c a u s e th ey regress to a m ore primitive
sta g e in th eir psych osexual development."

R e ifica tio n
A ssum in g th at an ab straction (e.g., personality traits, IQ, schizo­
p h renia) stand s for a real, c o n cre te entity.

• "He lacks courage."

• "He is b asically lazyf
• "Justice, beauty, an d virtu e are th e ultim ate form o f reality" (Greek
philosophers).
• "Sh e has less w illp ow er th a n others."
• "I'm havin g a nerv ou s breakdown."
 T h e . N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

H o m o ce n tric E rro r
A ssum ing th at th e h u m a n race is God's pet.

• "G od m ad e this planet for h u m a n beings." ’

• "The sun revolves arou n d the earth."

E g o ce n tric E rro r
C on clu d ing th a t sin ce you are th e c e n te r o f y o u r world, y ou are th e
cen ter o f ev ery o n e else's world.

• "Everybody shou ld treat m e nicelyT

• "I shou ld get w h at I w ant in life."
• "The world ou ght to b e fair."

S u b jectiv e E rro r
Believing that you ca u se o th e r people's b e h a v io r and em otio n s.

• "I a m sorry that I m ad e you feel depressed."

• "I am m a k in g m y h u sb a n d unhappy."

S lip p ery Slope

A ssum ing that w h at is true in a singular in stan ce is tru e in all fol­
low ing instances.

• "If w e allow th em to b a n o u r assault w eapons, they'll so o n b e b a n ­

ning o u r target rifles."

A p rio rism s
D educing facts from principles instead o f in d u cin g principles from
facts.

• "W o m en h av e few er teeth th a n m e n b e c a u s e th ey h a v e sm aller

jaws." (Aristotle)
• "M elting sn o w could not ca u se the Nile to rise, b e c a u s e th e e q u a ­
torial regions are to o w arm for snow." (Plato)
• "W h en p e o p le are nice to you th ey are ju st trying to get som ething."

O v erp o w erin g
A ttem pting to solve all p rob lem s b y bulld ozing o v e r them.

• "W h e n th e g o in g gets tou gh, th e to u g h get going."

• A lcoholism can b e solved b y w illp ow er alone."
• "All you need is heart." *
Countering Techniques: Objective
/

P o ssib ilities E q u al P ro b ab ilities

If it is p o ssib le for an ev en t to occur, th e n it is probable.

• "If s o m e th in g can g o w rong, it will."

• "I sh ou ld w orry a b o u t getting diseases from plants."
• "Flying in planes is dangerous."

A n e cd o ta l E v id en ce
C on sid ering o n e u n co n tro lle d case as p ro o f o f a larger principle.

• "I kn ow s o m e o n e w h o . . . "

A rg u in g Ad H o m in em
A ttacking th e o p p o n e n t instead o f th e o p p o n en t's argu m ent; also
"d a m n in g th e sou rce" or "p o in tin g to an oth er's wrong."

• "You had to h av e b e e n th ere and d o n e th a t to advise me."

• "You can 't k n o w w h a t you are talking a b o u t b ec a u se y ou don 't have
a c o lleg e degree."
• "You need to b e a drug addict to help a drug addict."

Ip se D ixit
Asserting that som eth in g is true b ecau se an au thority says so;
app ealing to authority. "Freud said . . . , Skinner said . . . , Ellis says
Beck says . . . , M e Mullin says . . . "

• "A fa m o u s professor at an Ivy League college believes . . . "

• "Four o u t o f five d octors b eliev e . . . "

C o m p etitio n
Ju d g in g o n e 's w orth b y always co m p a rin g o n e se lf to another.

• "1 am not skilled b ec a u se th ere are m a n y p eople w h o can do b et­

ter."
• "W in n in g is everything."

M y stificatio n
Explaining physical events by m etaphysical or esoteric interpreta­
tions.

• "M e m o rie s o f past lives o b tain ed b y age regression hyp nosis are
e v id e n ce for a fo rm e r life."
• "M a n y o f th e activities ch ron icled in the Old Testam ent a b o u t the
200 T h e N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

Exodus were caused b y a c o m e t th a t later b e c a m e th e p lanet Venus."

• " O u t -o f -b o d y e x p e rie n ces prove life co n tin u e s after death."
• "The m etal alloy Nitinol can b e b e n t b y p sych ic energy."
• "People can view o b je cts from a distan ce ev en th o u g h th e y d o not
have direct physical sight o f th e o b je c t (re m o te viewing)."
• "The Nazca lines in Peru were lan d in g fields for spacesh ip s b e a r in g
a ncien t astronauts."
• "The blu e sky, th e flickering o f stars, the N orth ern Lights, and
su n -s p o t activity are caused b y o r g o n e energy, th e b asic e la n o f life."
• "A m o th e r's ex p erien ces a day after co n ce p tio n will lea v e an im print
on th e u n co n scio u s m ind o f th e fetus."

C o rre la tio n E q u als C au satio n

A ssum ing that if tw o v ariab les are associated then o n e causes th e
other.

• "U n co n sciou s a n g e r at y o u rse lf causes all depression."

• "Planes cause fear since I o n ly h a v e fear in planes."
• "T h u n d er causes lightning."

Ig n o rin g C o u n te r E vid en ce
A ssum ing that all a th eo ry needs is s o m e e v id e n ce that su p p o rts it.
(This is n o t en o u g h ; o n e m u st also sh ow that th e e v id e n ce fo r a th e ­
ory is stron ger th an th e ev id en ce against it.)

• "Since so m e su b jects h av e o b ta in e d a high hit rate in psi research,

extrasensory p ercep tion has b e e n proven."
• "Since m o n o a m in e oxid ase inhibitors, tricyclics, and alp raz o la m
have red uced so m e clients' p an ic reactions, all panics are totally
biologically based and psychological therapy o f a n y so rt is u n n e c ­
essary."

O v erso cialized T h in k in g
O vercu lturated p eople are th o se w h o u n critically s u b sc rib e to th e
prevailing social attitudes and u n critically accept th e g e n era l cultural
belief. A form o f this fallacy called "argu ing ad p o p u lu m " m a k es state­
m ents th a t ap p eal to the c o m m o n preju dices o f th e masses.

• "A w o m a n 's place is in th e home."

• "M y cou n try right o r wrong."
• "M arriage shou ld b e 'til death d o us part."
• "You can't trust a n y o n e o v er 30."
Countering Techniques; Objective 201
/

• "Sp arc th e rod a n d spoil th e child."

• "P oor se lf-e steem is at th e b o t to m o f all psychological problems."

S e lf-R ig h te o u sn e ss
Believing th a t g o o d in ten tio n s are m o re im p o rta n t th a n outcom es.

• "But I was o n ly trying to help you."

• "E x trem ism in the defense o f liberty is n o vice."
• "V iolence is virtu ou s if its p u rpose is to rem ove injustice."
• "It's true b e c a u s e I m e a n t well."

S id e tra ck in g
C h an g in g th e su b ject o f a discussion to a non g erm an e, irrelevant
issue in o rd e r to h id e the w eakn ess o f one's positions. These strategies
are c o m m o n ly referred to as "red herrings."

1. Dishonest questions. Rapidly ask ing a series o f q u estio n s so that the

o p p o n e n t m u st stop th e a rg u m e n t to an sw er them.
• " W h y are y o u criticizing m e for b e in g late? Did you have a bad
day? W h y is this so im p o rta n t to you ? Are you havin g that PiVIS
p ro b lem again? H ave you g o n e to th e d o cto r a b o u t it? Is there
s o m e th in g else that you 're really angry about?"
2. Pointing to another's wrong.
• "Since you 've accused m e o f b e in g fat, w hat's th at spare tire
d o in g a ro u n d y o u r waist?"
3. A rcheological blam ing. Dredging up a past wrong.
• "You say I w as rude at the party. W h a t a b o u t last year's party
w h ere you em b a rra ssed the hell out o f me?"
4. Emotive language. Trying to get the o th e r person upset by using e m o ­
tio n ally load ed phrases.
• "You are so stupid, ugly, and d u m b th at you can't p ossibly know
a g o d d a m n thing! "
5. Ju d o approach. O veragreeing with a c o m p la in t so th at th e o th er per­
son w ithdraw s it.
• "You're right! I've b e e n cruel an d u n k in d to you. You have a per­
fect right to b e so upset. 1 a m really a hard person to live with. I
d o n 't see h ow you d o it."
6. Anger attack. Trying to sidetrack p e o p le by getting a n g ry at them.
M ost p e o p le will respond to the an ger and drop th eir position.
• "H ow d a re you criticize me! You have n o d a m n right to do so."
7. Invincible ignorance. Totally denying that there is any problem whatsoever.
202 T u t N e w H a n d b o o k o r C o g n it iv e T h e r a p y T e c h n iq u e s

v V
• "I h a v e a b so lu tely no idea w h at you are talking a b o u t. 1 didn't
have a n y th in g to drink at th e party."

F o re sta llin g D isa g re e m e n t

P hrasing one's point o f view so that it w ould b e difficult o r e m b a r ­
rassing to disagree with it.

• "Everyone shou ld kn ow that. . ."

• "As a n y fool can see. . ."
• "It is o b v io u s to a n y o n e w ith brains that. .
• "Unless you don't know an y th in g ab o u t the subject, it's clear t h a t . .

Tried a n d True
Suggesting that a b e lie f is true sim p ly b e c a u s e it rep resents th e tra­
ditional view (similar to oversocialized th in k in g ex c e p t th a t the ap p eal
is to tradition rath er th a n to w hat is p resen tly popular).

• "W hat w as g o o d e n o u g h for m y fath er is g o o d e n o u g h fo r me."

• "D on't c h a n g e horses in midstream."
• "That's o u r policy."
• "It's alw ays b e e n d o n e this way."

Im p re ss in g w ith L a rg e N u m b ers
A ssum in g th a t a th ou g h t is true if m a n y p e o p le b e lie v e it.

• "Fifty m illion A m erican s can 't b e wrong."

• "C ounseling isn't helpful b e c a u s e I c a n n a m e 10 p e o p le w h o w en t
for therapy and n o n e o f th em got better."
• "In a recent survey, h u ndred s o f d o cto rs r e c o m m e n d e d that. . ."
• "Get with it! Everyb od y w h o's a n y b o d y b eliev es this."

B eg gin g th e Q u estion
M ak in g a sta tem en t th a t sou n d s as if it is asserting a c a u s e - a n d -
effect relationship, b u t is really ju st restating th e s a m e assertion in
a n o th e r form (a type o f ta u to lo g y that takes for gran ted the v ery th in g
in dispute).

• "I avoid flying b e c a u s e I a m a cow ard" (part o f th e d e fin itio n o f

"cow ard" is to avoid things unnecessarily).
• "A nybody with this m u c h a n x iety m u st b e crazy" (the clien t's defi­
nition o f crazy is a n y b o d y with stron g u n co n tro lle d em otions).
• "Narcissistic personality is caused b y e g o ce n tric focusing."
Countering Techniques: Objective 203
/

A p p eal to Ig n o ra n c e
A ssu m in g that if y ou don 't u n d erstan d som ething, th en no o n e can.

• "I can't figure o u t w h y I get depressed. It m ust b e ra n d o m bad luck."

• "This c o n d itio n in g crap is just so m u c h bullshit. All you have to do
is tak e th e bull b y th e h o rn s and get so m e w illpow er and courage
to o v e r c o m e y o u r fears."

Further Inform ation

T h e fallacies c o m e from a variety o f sources. S o m e are m alapropism s,
tw o c o m e from A lbert Ellis (Ellis, 1985), b u t m ost can b e found in a
variety o f b o o k s o n logic (sec Fearnside & Holther, 1959). S o m e o f the
ex am p le s c o m e from G ardner (1957, 1981, 1991), Randi (1989, 1995),
Carl Sa g an (1995), Sp ragu e de C am p (1983), and Taylor (1965).

F in d in g t h e G ood R ea so n

Principle

T h ere is o n e typ e o f fallacy th at is so universal and so pernicious

that it deserves to b e treated separately from the others.
M o st clients b e lie v e in a cogn itive fallacy, a fa lla q ' th a t pollutes the
clarity o f th eir thinking. It's called "finding the good reason." It is based on
the fact th at clients h av e th e h a b it o f m ak in g things up ju st to m ake
th em selv e s feel g oo d . It d o esn 't m atter that a thou ght is false or that
th e client lacks g o o d ev id en ce for believin g it. M a n y clients accept it
for th e very basic, sim p le reason th at it feels g o o d to b eliev e it.
T h e fallacy m a y b e defined as: "D efending a position b y picking the
m ost fa v o ra b le so u n d in g argu m ent, rath er than c h o o sin g th e most
logical o r ration al one." M o r e sim ply it m e an s that clients feel first and rea­
son second. M a n y clients first h av e a n e m o tio n and then search around
for the b e s t-s o u n d in g a rg u m e n t o r th e m ost rational ex p la n atio n for
their feeling. T hey then offer their ch o sen ration alization as th e sole
rea so n fo r th e ir belief.
T he ex p la n a tio n s h av e n o th in g to do with w h y clients b eliev e as
th ey do. T h ey sim p ly m a k e up the logic to support their em otions.
T heir feelings d o th e driving; their logic hitchhikes alon g for the ride.
Finding th e g o o d reason is a v ery d am agin g fallacy. It destroys per­
c ep tio n o f the truth and im plies that o n e side is correct w hile the o th er
side is worthless. But th e m ost dam agin g th in g a b o u t this fallacy is
204 The New H a n d b o o k qf C o g n it iv e T h e r a p y T e c h n iq u e s

that clients stop lo o k in g for tRe truth at all. Instead, th ey sp e n d their

tim e search in g for th e m ost c o n v in c in g w ay to sh o w that th e y are
right. This leaves little tim e and less en erg y to, find o u t w h e th e r th ey
w ere right in the first place.
T h e fallacy can b e fatal to so m e clients. Using this fallacy can cre­
ate a personal h o lo cau st th at p e rm a n e n tly destroys th e clien t's life.
Finding th e b est reason s for sy m p to m s protects th o s e sy m p to m s from
changing. It's like b uild ing a wall a ro u n d th e p ath o lo g y so th a t n o th ­
ing can reach it. An addict w h o has an ex cu se to sn o rt c o c a in e will
keep o n using, a suicidal person w h o feels justified in h a tin g th e world
m ay su cceed in an attem pt, a m arried partn er w h o keeps b la m in g his
o r her sp o u se will en d up with a b ro k e n m arriage. Finding th e g o o d
rea so n locks p rob lem s in place and keeps p e o p le fro m so lv in g them.

E x a m p le
Clients w h o are addicted e m p lo y th e fallacy perfectly. W h e n e v e r
th e y drink or use th ey search for the b est ex p la n a tio n for why. O u t o f
all the possible reasons they pick the ju stification that m a k e s th em feel
th e b est an d puts th em in the b est light. S o m e addicts say th ey 'v e
earned their b in g es b e c a u s e th ey w orked h ard all week. O thers say
that th eir sp o u ses drive th e m to drink. S o m e suggest th ey n ee d to
d rin k to calm th em selv es down, and so on, ad n au seam . T h e excu ses
are always the m o st flattering reason s th ey ca n th in k o f for drinking
o r drugging.
O th er clients use the fallacy. A n x iou s clients ex p la in th eir fears by
saying that th ey aren't resp o n sib le for b e in g scared. "It m u st b e
b eca u se so m e th in g terrible h a p p e n e d w h en I was young." T h eir "g o o d
reason" m ak es th em feel like n o b le victim s h eroically struggling
against an in su rm o u n ta b le past. W h at causes clients to b e afraid to d a y
is w h at th ey tell them selves in th e present, n o t the o c c u r r e n c e o f so m e
a n cien t event.
Angry clients insist that th ey are justified in feeling bitter. "The world
is such an unjust, unfair p lace'th a t I have th e right to b e angry." Their
exp lan ation implies that th ey are su p erio r to others b e c a u s e th ey have
a h ig h er sense o f ju stice and fairness th a n the rest o f humanity.
Alm ost all clients with m arital p ro b lem s b la m e th eir spouses. "The
relationship w ould w o rk if h e (or she) w eren 't so selfish.'' T h e im plica­
tion is that since they are perfect sp o u se s th ey m u st h a v e had th e m is­
fo rtu n e o f b e in g stu ck w ith an inferior partner.
Countering Techniques: Objective 205
0

M eth od
Possibly th e b est m e th o d o f u n d ercu ttin g this fallacy is to tell clients
to recognize th eir ten d en cy as h u m a n b ein g s to try to find th e goo d
reason a n d to offset this b y actively searchin g for the worst reason. I
o ften tell clients, to "Go out and find th e worst reason for believing
s o m e th in g and put this n ex t to y o u r b est reason. Then, b y h a v in g b o th
th e b e st and w orst sitting to g eth er in y o u r brain, you can m ore easily
find th e real reason."

E x a m p le
H ere are s o m e o f th e b est and w orst reasons m y clients have devel­
oped fo r variou s positions.
Position: Being an alcoholic.
Best R eason: "1 have had a p o o r u n fo rtu n a te childhood."
Worst R eason: "I a m a d ru n k w h o w o n 't adm it it."

Position: H aving a phobia.

Best R eason: "1 am an em o tio n a lly sensitive person w h o can perceive
dangers th at o th ers miss."
Worst Reason: "I'm a cow ard w h o doesn't have e n o u g h guts to face
m y fears."

Position: P rob lem s in a m arriage

Best R eason: "M y sp o u se is insensitive to m y needs."
Worst R eason: "I a m a spoiled brat w h o is not willing to pull m y own
w eight in th e relationship."

C om m en t 1
It is o b v io u s th a t n ot o n ly clients use this fallacy. We all sh are it. For
exam ple:
Position: Ticketed for speeding.
Best Reason: "These cops have n o th in g to d o b u t harass p o o r honest
citizens."
Worst R eason: "I a m an arrogan t s o n - o f - a - b it c h w h o thinks th e law
sh o u ld n 't apply to me."

Position: Politically conservative.

 T hf . N e w H a n d b o o k o f C o g n i t i v e T h e r a p y T e c h n i q u e s

Best Reason: "I am a patriot w h o w ishes to m ain tain th e b e st policies

that m y c o u n try has ta k e n d ecad es to develop."
Worst Reason: "I w ant to hold o n to all th e m o n e y 1 m a d e u n d e r the
old system, and 1 don 't w ant a n y b o d y else to get a n y o f it.

Position: Politically liberal.

Best Reason: "I w ant to im p rov e society in ever}' w ay p ossib le so that
it b e c o m e s m o re e q u ita b le and b en eficial to all people."
Worst Reason: "I don 't have th e skill, industry, o r gu ts to m a k e it in a
com p etitiv e world, so w e sh o u ld c h a n g e ev ery th in g to give m e a
b etter c h a n c e in a new system."

Position: Being a Freudian therapist.

Best Reason: "This is th e o n ly system for w o rk ing o n th e u n d erly in g
causes o f em o tio n a l p rob lem s; all o f th e o th ers ju st w o rk o n the
surface symptoms."
Worst Reason: "It takes clients years to c o m p le te this therapy. T hink
o f all the m o n e y I can rack up."

Position: Being a c o g n itiv e -b e h a v io r a l therapist

Best Reason: "It's th e m ost scientifically p recise and carefu lly
research ed method."
Worst Reason: "I can't stand am biguity. Feelings and e m o tio n s are
sloppy and disconcerting; I need things to b e clean an d orderly^'

Position: Being a New Age therapist.

Best Reason: "I b eliev e that w e need to treat th e total p e rso n — spiri­
tual, em otio nal, b eh a v io ra l— n ot to dissect th em in to m in u te little
parts."
Worst R eason: "I could n ev er pass a g ra d u a te p rog ram o f scientifically
based therapies. M y th e o ry is so fuzzy an d eth ereal th at n o o n e can
ju d ge w h e th e r I kn ow a n y th in g or not."

C om m en t 2
"Finding th e g o o d reason" is sim ilar to th e c o n ce p t o f "ration aliza­
tion," w h ich has lon g b e e n estab lish ed in psychology. W e use th e c o n ­
cept here m o re as a self-rein forcin g cogn ition ; th e p e rso n b eliev es
s o m e th ou g h t sim p ly b e c a u s e it feels g o o d to b e lie v e it. W e co n tra st
this m e a n in g w ith the old er p sy ch o d y n a m ic view o f ratio n aliza tio n as
Countering Techniques: Objective
/

b e in g a d efen se m e c h a n is m o r psychological strategy to avoid the

a d m itta n c e o f u n w a n te d u n co n scio u s m aterial into consciousness.

F u rther In fo r m a tio n
This fallacy is well know n to th e public, see Bowler's (1986) b o o k The
True Believers.
I h e b est co u n te rs to this fallacy do not c o m e from psychologists,
psychiatrists, philosophers, logicians, or scientists, but from humorists.
W h a t m akes so m e h u m o rists so fu n ny is their ability to suddenly
s h o c k us into seein g w h a t underlies people's su rface explanations.
Readers will u n d o u b te d ly h av e th eir ow n list, b u t m y favorite
h u m o rists that e x p o s e h u m a n facades are Dave Barry (1994, 1996,
1997), and o f c o u rse the classic ex p oser— M a rk Twain (see particularly:
Twain, 1906, 1916, 1962, 1972a, 1972b, 1980).
 Perceptual Shifting:
Basic Procedures

T used in cogn itiv e restructuring th er­

h e m o s t in n o v a t iv e t e c h n iq u e s

apy derive from perceptual shifting theory.

T h ese tech n iqu es focu s o n clients' overall perceptions. W h ile the
c o u n te rin g chapters in this b o o k em p h a size c h a n g in g clients' internal
dialogues o r self-language, perceptual shifting aim s m o re b ro a d ly at
m od ifyin g th e general pattern o f the w ays clients lo o k at th e world.
This b ro a d er focus deals with p erceptual patterns, gestalts, schem ata,
and them es.
Perceptual shifting is covered in th ree chapters. "Basic P rocedures"
discusses th e fu n d am en tals o f the shifting tech n iq u e. "Transposing"
m ak es creative use o f picture an alog ies to help clien ts to c h a n g e th eir
perceptions. Clients are sh o w n a m b ig u o u s draw ings a n d h id d en pic­
tures a n d asked to shift from o n e im age to another. After they lea rn to
shift im ages perceptually, th ey use th e s a m e te c h n iq u e s to shift their
thou ghts conceptually. "Bridging" teach es th e therapist to search for
a n ch o rs that can carry clients' old beliefs tow ard new ones. C lient v a l­
ues, w ord labels, and th erap ist-created asso cia tio n s are all u sed as
anchors.
T here is m u ch e v id e n ce in su p p ort o f this perceptual shifting
approach scattered th ro u g h o u t psychological literature. It is e n c o m ­
passed u n d e r su ch phrases as:

• Sleep and dream research • C on d ition ed seeing

• Altitude ch a n g e th eo ry • O p e ra n t seeing
• A m b igu ou s pictures • C o n tex tu a l o rg a n iz atio n in
• Gestalt p sych ology co g n itiv e p sych ology
• Insight "Aha" ex p erien ce* • D ram atic life ch a n g es
Perceptual Shifting; Basic Procedures

C o n tin g e n cy vs. contigu ity in Constructionistic vs. rationalistic

classical co n d itio n in g F ro n ta l-lo b e vs. b ra in -stem
P ersonal "m ean in g s" and c o n ­ fu n ctio n in g
ceptu al "clicks" Visual perceptual psychology
Religious co n v ersio n C ognitive d evelopm ental th e­
"B rainw ashin g" ory
Logotherapy C ognitive neu roscien ce
Floo d ing Neural netw orks
Perceptual focu sin g Linguistical prototypes
Split brain h em isp h e re C on nectionist vs. serial digital
research inform ation processes

A lth o u g h th e variou s perceptual shifting tech n iq u es differ greatly

in th eir m eth o d ologies, all reflect the following c o m m o n assum ptions:

1. The brain selectively screens sensory and proprioceptive data.

2 The b ra in form s these data into patterns.
.

3. T h e patterns that th e b ra in form s are influenced b y incom ing

data, b u t rem a in distinct from it.
4. In m ost cases, these patterns are learned in the sa m e w ay that the
b rain learns o th e r inform ation. However, so m e patterns are
instinctual, and trigger a u to m atic em o tio n a l and beh avio ral re­
sponses.
5. T h o u g h th e re are an infinite n u m b e r o f possible patterns, the
b rain uses o n ly a few personalized schem ata.
6. O n c e form ed, patterns have a te n d e n c y to persist unless u n ­
learned.
7. M o st patterns a rc tau g h t by significant o th ers (family, reference
grou p, culture).
8. The m o r e frequ en tly a pattern is repeated, the stron ger it gets and
the m ore difficult it is to rem o v e o r replace.
9. Patterns are form ed m o re easily an d have m o re staying p ow er in
th e y o u n g e r brain.
10 . E m o tio n al and b eh a v io ra l resp on ses are triggered b y th e brain's
patterns rath er than by th e individual stimuli, th o u g h individual
stim uli are often m istak en ly b elieved to b e the sole sources o f a
client's responses.
11. Classical and o p e ra n t c o n d itio n in g can asso ciate em o tio n s and
b e h a v io rs to th e patterns.
12. E n v iro n m e n ta l stim uli can b e c o m e con d ition ed to th e patterns.
Later, th ese triggers alo n e develop th e ability to elicit the patterns.
210 The N e w H a n d b o o k of C o g n it iv e T h e r a p y T e c h n iq u e s

13. Language and im ages a r e 'w a y s o f d escrib in g th e patterns, b u t

th ese patterns arise prior to la n g u a g e o r visual rep resen tations.
14. C h an g in g th e rep resentational description o f th e p atterns m ay
loop back and c h a n g e the pattern itself, b u t it is n ot a o n e - t o - o n e
relationship.
15. Patterns are n o t gen erally form ed o n a logical basis, b u t m o re
usually th rou g h e m o tio n a l-e x p e rie n tia l learning.
16. If a pattern is incom p lete, th e b rain will m a k e an a u to m a tic c lo ­
sure.
17. S o m e patterns, o n c e form ed, m a y b e im m u table.
18. If a pattern c a n n o t b e im m ed iately ascertained, a state o f p a n ic is
produced.
19. T he quickest, m ost co m p le te m e th o d o f m o d ify in g n eg ativ e e m o ­
tions and n o n a d a p tiv e b eh a v io rs is to c h a n g e the p atterns that
elicit them.

W h a t exactly are these patterns that a p p e a r so essential to c o g n i­

tive therapy? First understan d that th e word "pattern" is used arb i­
trarily. O th er terms, in clu d in g "schemata," "themes," "meanings," or
"gestalt," could b e em ployed, b u t "pattern" has a b r o a d e r c o n n o ta tio n .
A pattern is th e w ay th e brain organizes raw data, w h ich m a y b e
a n y th in g that the b ra in is aw are of: in pu t from th e se n se organs, from
m e m o ry storage, from b o d y sensations, o r from su b co rtica l regions o f
the brain. T he brain takes separate bits o f in form ation , w h ich viewed
alo n e w ould b e m eaningless, and grou ps it into patterns. T hese pat­
terns im p o se ord er o n to th e world. A pattern is n ot sim p ly la n g u ag e
or images, b u t w h a t clients refer to w h en t h e y are se a rch in g for th e
right w ord o r im age to d e scrib e w h a t th ey are thin king . T h ere are
m a n y nonvisual, n on linguistical patterns. A m e lo d y play ed o n a pian o
rem ains th e sa m e ev en if played in a different key; similarly, a s e n ­
ten ce can b e w ritten w ith different w ords b u t c o n v e y the s a m e m e a n ­
ing. B o th th e m e lo d y a n d th e m e a n in g o f th e s e n t e n c e are
patterns— th e notes and w ords are not. T h ey a re th e w ays that w e
c o m m u n ic a te patterns. Even anim als th at h av e n o lan g u ag e a n d blind
p e o p le w h o h av e no visual im ag ery still use patterns.
All p e o p le h av e n o n v erb al, n o n v isu a l patterns. An e x a m p le w ould
b e a flight o f stairs w e h av e w alked d o w n a th o u s a n d tim es b e fo re and
n o lon g er lo o k at w h ile descending. W e b e c o m e aw are o f th e pattern
(in this case kinesthetic) o n ly i f it is m istaken . If a n o t h e r step is
expected w h e n th e r e isn't one, o u r foot is jo lte d b y h ittin g th e b o tto m .
O n ly th e n d o w e realize that^our pattern was off.
In the pages th at follow, I briefly in tro d u c e th e u n d erly in g p r in c i-
Perceptual Shifting: Basic Procedures 211
/

pies a n d a ssu m p tio n s for each o f the p a tte rn -c h a n g e techniques. I

su m m a riz e th e steps th e therapist shou ld take in ex ecu tin g the tech­
niqu e, provide ex am p le s o f the tech n iqu e's successful use, and then
en d e a c h discu ssion with helpful c o m m e n ts and a list o f references
w ith fu rth er inform ation.
A key p oint deserves e m p h a sis here. For the purposes o f this pres­
entation, the tech n iq u es are covered individually and in detail. How­
ever, th e singularity o f o u r focus o n each o n e shou ld not o b sc u re the
e x te n t to w h ich a skilled therapist m ay c o m b in e th em into a coordi­
nated p attern for positive change.

B a s ic P er c ept u a l S h ift

Principles

W h ile analyzing su bjects' dream s, H ob son and M cC arley (1977) o f

H arvard discovered so m e interesting facts a b o u t the h u m a n brain that
not o n ly m ak e sense o u t o f h ow th e brain fu nctions during sleep, but
also give clues a b o u t h o w it w orks w h en awake.
A cco rd in g to their research, th e brain does m ore th a n receive, store,
and retrieve n e u ro c h e m ic a l inform ation. It transform s inform ation,
o rg an izin g raw bits o f data into schem ata, patterns, and them es. The
sen ses feed th e b ra in m ost o f th ese raw data w h en th e organism is
awake. W h e n asleep, the brain uses m o re in tern al data from lo n g - and
s h o r t-te r m m em ory, em otio n s, and the organism 's present physical
stim u lation. In b o th states, (he fo rebrain organizes th e data provided
b y th e rest o f th e b rain into co h eren t patterns, synthesizing th e data
in to larger w holes. In sleep th e b rain's sy n th eses are called dreams.
Awake, th ey are called beliefs, attitudes, and thoughts.
M a n y neg ativ e e m o tio n s o c cu r b e c a u s e clients synthesize raw data
in to m a la d a p tiv e them es, co n tin u ally organizing in form ation into
fearful, depressing, o r angry patterns. A lon g history o f th in king dis-
tortedly— a lo n g with th e strong em o tio n a l arousal this creates— m akes
th ese th em es prepotent, so that the b rain consisten tly selects th e sam e
in terp retation from its repertoire, n o m atter how inapp ropriate it is to
th e present circum stances.

M eth o d
1. Have y o u r client draw fou r c o lu m n s o n a large piece o f paper (see
ta b le 7.1.) In the first co lu m n , have th e client list ev ery thou ght or
212 T h e N e w . H a n d b o o k o r C o g n it iv e T h e r a p y T e c h n iq u e s

T ab le 7.1
Perceptual Shift Worksheet

Thought/Belief Useful Your Best Evidence from Your

or Argument against Own Experience
Not Thought Proving the Best
Argument

*
Perceptual Shifting; Basic Procedures 213
/

b e lie f th a t causes negative e m o tio n s in a particular situation (e.g., "1

a m afraid to fly in planes b e c a u s e I could gel scared and all the
o th e r p assengers w ould se e it," o r "Planes are d ang erou s b ecau se
you c a n 't escape"). O bviously, th e list c a n n o t g o o n indefinitely.
However, ev en if s o m e o f th e th ou g h ts seem repetitious, it is b etter
to in clud e th e m th an to leave a m a jo r th e m e unrecorded.
2. In th e se co n d co lu m n , help y o u r clients decide w h e th e r each b elie f
is useful o r not useful. Look for th e ev id en ce b o th for and against
it, a n d d e te rm in e w h ich is stronger. It is essential that clients m ake
this decision b ased o n o b je ctiv e data rather th an su b jective feelings.
3. In th e third co lu m n , h av e th e client record the b est argu m en t
against e a c h th ou g h t or belief. Ideally, this arg u m en t will b e e m o ­
tio n a lly p ersuasive as well as rationally sound.
4. In th e last co lu m n , h av e the client list the ev id en ce in support o f
e a c h argu m ent. This is the key to th e perceptual shift technique.
W ith th e a ssistan ce o f the therapist, th e client sh ou ld prove that the
a rg u m e n t is correct b y searchin g o u t ev id en ce from his or h e r own
life exp eriences. For instance, re m e m b e rin g and stating th at 20
p an ic attacks n ev er caused a psychotic b rea k effectively argues
against th e th o u g h t th a t p an ic attacks ca u se insanity, and it does so
b y using n o t o n ly abstract logic, b u t the client's ow n exp erien ces as
well.
5. To b rin g a b o u t th e actual perceptual shift, th e client shou ld m edi­
tate at least 30 m in u tes a day o n th o se critical past incidences that
disprove th e irrational them e.

Exam ple 1
In th e years th at I h av e counseled agorap hobics, I h av e isolated o n e
b a sic false b e lie f that prod u ces m ost o f their anxiety: "I could lose c o n ­
trol o v er myself." T h rou gh th e use o f the cogn itiv e tech n iq u es covered
in this b o o k , m ost clients h a v e b e e n a b le to purge these and o th er
beliefs, and to significantly red uce or elim in ate their panic attacks.
T h ey didn't shift th eir p ercep tio n quickly; m a n y w o rk ed for m ore than
a year. But b a sed on self-rep orts, o b je ctiv e tests, b e h a v io ra l measures,
a n d collateral reports, th e average client w as ab le to red uce anxiety
significantly.
However, ev en after successfully shifting th e co re b e lie f and b ein g
p a n ic -fre e for a year, alm ost all clients still feel so m e residual, low -
level ten sio n ; they often m e n tio n feeling slightly on guard.
S o m e tim e ago, o n e o f m y patients d escribed this feeling. Sh e asked,
214 T u t N ew H a n d bo ok of C o g n it iv e T h e r a e y T e c h n iq u e s

"If the p an ic I used to h av e is called a g o ra p h o b ia, w h a t is this ten sio n

I'm having n ow called?" Not h aving a n im m e d ia te answer, I m a d e o n e
up, and said, "Let's call it 'Harold.'" Sin ce th a t time, I h av e told m a n y
clients o f "Harold" and often use th e n a m e to d e scrib e th e feeling.
W h a t is H arold? W h e re does this lo w -lev el ten sio n c o m e from ? It is
m y h y p o th esis that "Harold" is the p o s ta g o ra p h o b ic feeling o f vigi­
lan ce and ten sio n th a t clients create to protect ag a in st th e p a n ic o f
a g orap hobia. Harold guards against losing control. As o n e client
d escribed it: "I have to b e on gu ard and feel a little tw in g e o f an xiety
b ec a u se th e n I will b e prepared fo r m y panics. If I get to o relaxed then
th e p a n ic m a y sn e a k up o n me."
Harold is like a sentry on gu ard against a g o r a p h o b ic p an ic; h e stays
on duty long after th e c o n d itio n is gone. T he a g o r a p h o b ic fear m ay
h av e disappeared for several years, the client m a y feel th at h e o r she
will n ev er again fear losing control, b u t Harold c o n tin u e s u nabated . It
often seem s m o re difficult to rem o v e this g u a rd ia n o f d a n g e r th a n it
w as to re m o v e th e d an g er itself.
Harold is not an a n th r o p o m o rp h ic entity. Like a n y o th e r fear, it is
triggered b y a series o f th ou g h ts an d beliefs, a n d like a n y o th e r fear, it
c an b e shifted using th e b asic perceptual shift, as th e follow ing case
history dem onstrates.

E xam p le 2: The Story o f Denise

D enise initially c a m e to see m e fo r a g o r a p h o b ic anxiety. Afraid to
travel far from her h ou se, s h e h ad restricted h e rs e lf to a fiv e -m ile
"safe" radius (the ag o ra p h o b ic's "territory"). U sing co g n itiv e te c h ­
niques, s h e h a d elim in a te d h e r fears in 6 m o n th s' tim e, and had flown
a lo n e on several o ccasion s to visit h er relatives— s o m e tw o th ou san d
m iles aw ay— w ith o u t feeling a n y panic. By the tim e s h e retu rn ed for
add ition al therapy s h e no lon g er feared losing co n tro l o r b e c o m in g
psychotic. However, sh e still felt lo w -lev el ten sio n (Harold) and
w anted to d o s o m e th in g directly to red u ce it.
Her w o rk sh eet look ed like this:

C o lu m n 1. T h o u g h ts o r Beliefs R ela ted to H aro ld

1. If I don 't c o n sta n tly w a tc h o u t for a g o ra p h o b ia it co u ld sn e a k up on
me.
2. I m u st b e prepared to es ca p e in ca se a g o ra p h o b ia c o m e s back. I
m ust m a k e su re all m y escap e paths are clear.
5. A w a tch ed pot n e v e r b o ilS— w a tch ed a g o ra p h o b ia n e v e r boils. (If I
k e ep lo o k in g for it, it is less likely to happen.)
Perceptual Shifting: Basic Procedures 215
/

4. i need to th in k a b o u t m y past a g o rap h o b ia all the time, b ecau se

th en I will h a v e all m y tools ready w h en I need them. If I forget
h ow to use m y tools, t h e n a g o ra p h o b ia could get m e again.
5. I m u s t n ev er allow m y se lf to b e lo o calm , too relaxed, or to o happy,
b e c a u s e m y gu ard would b e down.
6. M y panics will c o m e back unless I co n sta n tly worry a b o u t them
c o m in g back.
7. A ny tim e I feel calm I'm just foolin g myself, b e c a u s e agorap hobia
m a y b e lurking in th e backgrou nd.

C o lu m n 2 . Useful o r Not Useful

D enise rated all o f th e se beliefs not useful, but was o n ly a b le to do
so after th in k in g o f an analogy. Sh e im agined a m a n w h o believed that
plants could infect h im with a terrible disease and w h o was afraid o f
to u ch in g them . Sh e th en pictured th e sam e m a n as h a v in g erased his
irrational fear a n d b e in g ab le io touch a n y plant h e w anted, b u t still
feeling ten sio n w h e n e v e r h e was a ro u n d plants. T hrough this analog)'
s h e was ab le to see th a t his co n tin u in g fear arou n d plants was as
u n n ecessa ry as h e r co n tin u in g fear o f losing control. Specific reasons
b e h in d this b e lie f b e c a m e ev id en t in th e third c o lu m n o f h e r w ork­
sheet.

C o lu m n 3. Best A rg u m e n t A gain st Belief

1. Sin ce losing co n tro l doesn't cause psychosis, I don 't have to guard
against it.
2. W atch in g o u t for the d an g er will increase m y fear w ithou t reducing
th e danger.
3. Sin ce th e re is n o real danger, there is no real reason to guard.
4. It is b e tte r to get an x io u s o n c e a m o n th for a n h o u r o r two th a n to
sp e n d th e w h o le m o n th w orrying a b o u t getting anxious.
5. W atch in g for a n x iety doesn't red uce the c h a n ce o f getting it.
6. Letting m y self forget that I was an a g o ra p h o b ic will ju st m a k e m e
feel better, a n d it w o n 't m a k e it m o re likely that th e a g o ra p h o b ia
will return.

C o lu m n 4. E v id e n c e P ro v in g th e Best A rg u m e n t
1. T he client re m e m b e r e d all th e incidents w h en sh e got panicky
despite w atch in g for it, an d all th e tim es it didn't o c cu r w h en she
w asn't w atching. S h e co n ce n tra te d on the plant an alog y and
rem in d ed h erself th a t gu ard in g against a terrible plan t disease
d o esn 't red u ce th e c h a n c e o f catchin g o n e if plants are unlikely to
give terrible diseases.
 T he N ew Han d bo o k qe C o g n it iv e T h e r a p y T e c h n iq u e s

2. Sh e rem em b ered the s c o r e s 'o f tim es sh e h ad feared th e retu rn o f

a g o rap h o b ia w ithou t it havin g hap p en ed . All th at h e r fear did was
to give h e r pain w ith o u t providing a n y real protection.
3. S h e th ou g h t a b o u t ch ild h o o d fears, su ch as m o n sters u n d e r the bed
or tigers in the w o od s, an d h o w silly it is for a child to run aw ay
from them. Sh e related th ese ch ild h o o d fears to the fear o f goin g
crazy o r havin g a nerv ou s breakd ow n.
4. S h e sp eculated a b o u t all the th in gs s h e could h a v e d o n e in stead o f
gu ard in g against ag o rap h obia, su ch as read ing b o o k s , taking
courses, ren ew in g friendships, playing with h e r children, sm ellin g
roses.
5. Sh e reflected o n all th e pots in life that boil w h e th e r w e w atch th em
or not. Children grow up. Love dies or deepens. O u r w o rld changes.

In keep in g with the last step o f th e process, th e client reh earsed the
b asic perceptual shift tech n iq u es o n a d eceleratin g schedule. In the
beginning, sh e practiced every day, th en e v e n ' o th e r day, then o n c e a
week, then o n ly as needed. Sh e was instructed to try to shift Harold
only during th e practice periods. At o th e r tim es sh e c o n c e n tr a te d on
o th e r aspects o f h er life, an d found th at this te c h n iq u e w o rk ed . Sh e
has not th ou g h t o f Harold for m a n y years now.

Continent
T he perceptual shift te c h n iq u e h a s a great a d v an ta g e o v er m a n y
o th e r tech n iq u es in that it can b e effectively used in a crisis and it
attacks all the relevant co g n itio n s ca u sin g th e crisis. Sin ce it is an
ad v an ced tech n iqu e, the therapist shou ld e m p lo y it o n ly after m ore
p relim inary cogn itiv e ap p ro a ch e s h av e b e e n presented.

F u rther In fo r m a tio n
This treatm en t is a variation o f a te c h n iq u e d escribed b y M e M ullin,
Assafi, and C h a p m a n (1978) a n d M e M u llin and Giles (1981).
B a u m b a c h e r (1989) describes Harold m o re eleg a n tly as "signal a n x ­
iety." He discusses how p an ic clients m isp erceiv e th e first p h y siologi­
cal sen sation s associated w ith anxiety, a n d h ow this m isp ercep tio n can
lead to a fu ll-b lo w n p a n ic response.
Presently m ost cogn itiv e therapists are lo o k in g at Bs as n o n lin e a r
th em es o r sch em as (see Beck, 1996; Bricker, Young, & Flanagan, 1993;
Ellis, 1996; M ah oney, 1993b , J 994; M cG in n & Young, 1996). "
 /

EIGHT

Perceptual Shifting:
Transposing

T he C O M M O N FEATURE IN tran sp osin g tech n iqu es is the use o f

all

a m b ig u o u s draw ings to teach clients h ow to shift their perceptions.

O n c e clients h a v e m astered shifting from o n e im age to another, they
are ta u g h t to use the s a m e tech n iq u es to c h a n g e their cognitions and
attitudes.
Initially, a m b ig u o u s draw ings were used sim ply as an analogy to
illustrate w h a t perceptual shifting m eant. Clients were show n o n e or
tw o im ages and th en im m ed iately set to w o rk on their attitudes and
beliefs. B u t clients often asked to see the pictures again, stating that
th ey w an ted to discov er how th ey were a b le to ch a n g e w h at th e y saw.
T h ese requ ests w ere often expressed right in the m iddle o f w o rk ing on
o n e o f th eir cognitions, and w ere often con sid ered a distraction or a
sidetrack to th e real purposes o f counseling. Later w e realized that the
clients found h av in g th e se pictures accessible very helpful in u nder­
stan d in g w hat they needed to do w ith their cognitions. We therefore
in co rp o ra ted the a m b ig u o u s draw ings as a m a jo r c o m p o n e n t in train­
ing clients to m a k e p ercep tu al shifts.
The draw ings have th e ad v antag e o f b e in g b o th n o n v erb a l and
g lo b a l— n o n v e rb a l b e c a u s e th e im ages em p hasize that brain patterns
are m o re b a sic th a n clients' verbal descriptions o f them , an d global
b e c a u s e th e draw ings illustrate that perceptual shifting requires w ork­
ing with the pattern o f stim uli rath er th an with th e individual stim u ­
lus. W e h av e found tran sp osin g tech n iq u es a m o n g o u r m ost valu able
procedures.
218 T h e N e w H a n d b o o k o r C o g n itiv e T h e r a p y T e c h n iq u e s

T r a n s p o s in g Im a g es

Principles

We have m a d e fre q u e n t use o f reversible im ages to tea ch clients

a b o u t h ow th eir b ra in s o rg a n ize th e s a m e in fo rm atio n in to different
patterns, an d how they c a n learn to shift th e p attern s that are h a r m ­
ful to them.
T h e te c h n iq u e involves sh o w in g clients reversible draw ings o r hid­
den figures in w hich the raw m aterial for a w ide ran ge o f c o n cre te
im ages is hidden. T h e clients' m in d s extract o n e o r th e o th e r image(s),
d ep en d in g u p o n th e m a n n e r in w h ich th ey are c o n d itio n e d to p ro­
cessing inform ation.
In th e follow ing pages, w e will sh ow two m e th o d s o f u sing trans­
posing techniques.
Look first at figure 8.1. Clients usually see e ith e r th e im a g e o f a
witch or th e im age o f a y o u n g w o m a n from this a sse m b la g e o f b lack

F ig u r e 8.1 O ld w o m a n - y o u n g w o m a n v is u a l a n a lo g ) ' o f t r a n s p o s it io n .
D ra w n b y c a r t o o n is t IV. W . H ill, p r ig in a lly p u b lis h e d in P u c k , N o v e m b e r 6 1 9 1 5
L a te r p u b lis h e d b y E. G. B o rin g , 195 0 .
Perceptual Shifting.: Transposing 219
/

ink lines o n w h ite paper, b u t n eith er im age is really in the picture. The
p ercep tio n is th e result o f th e ir b rain 's effort to organ ize th e raw m ate­
rial into a m ean in gfu l pattern. T he raw m aterial reflected o n th e retina
is th e sam e, b u t different clients will interpret different images.
If, th ro u g h cond ition ing , clients asso ciate pain with the im age o f the
w itch and pleasure with the im age o f the y o u n g w om an , then the
result o f th ese percep tion s will p rov oke eith er the positive o r negative
em o tio n . Rem em ber, th e raw m aterial o f th e d raw in g doesn't create
the em o tio n s; th e b ra in does.
U sing the picture as a guideline, w e h y p o th esiz e that m a n y clients
w h o are unhappy, anxious, o r depressed have learned to see "w itch-
type" im ages in th e w orld a ro u n d them . O r m ore precisely, sin ce the
w itch is n o t "in" th e picture, th ey h av e learned to see w itches in
a m b ig u o u s data. To rem ove their negative em otion s, therapists need
to help clients to see the y o u n g w om an.
A ny o f several strategies m ay b e em p loyed in helping clients to d e s-
tigm atize seein g witches. T h rou gh con d itionin g , w e can pair relaxation
w ith percep tion s o f w itches (see o u r discussion o n cognitive desensi­
tization). W e can also train clients to see o n ly th e y o u n g w o m an, thus
a v o id in g a n y d iscom forts that m ight b e incited b y th e o th e r image.
A k e y p oint to b e em p h asized here is that w hat is true for clients'
p ercep tio n s o f th ese draw ings is also true for clients' perceptions o f
them selves. If clients form gestalts that screen out m ost positive data,
th ey will "see" a negative world. If their brains c o n tin u e organizing
a m b ig u o u s stim uli into dang er th e y will feel anxious. And if they
o rg a n ize their en v iro n m e n ts into b e in g treated unjustly, th ey will feel
c h ro n ic anger.
T he tran sp osin g te c h n iq u e em phasizes ch an gin g clients' general
p attern s o f thinking, th eir gestalten, the way their brains organize
th eir exp eriences. Using th e a n alog y o f reversible or em b ed d ed fig­
ures, w e h a v e b e e n ab le to help clients to restructure th e ir gestalten
in to m ore-realistic, le s s-d a m a g in g co n ce p tu al wholes.

M eth o d 1. Reversible Images

1. A ssem b le a useful collection o f reversible images (see figures 8.1, 8.2,
and 8.5, and the section on Further In fo rm atio n for add ition al ref­
erences).
2. S h o w clients a series o f reversible figures. At least four figures are
used. Show' the figures to them o n e at a time, and ask you r clients
to tell y ou w h at they see. Ask th e m to try to see an alternative fig-
220. T u t N ew H a n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

Donkey/Seal Old Man/Young Man M an /W o m an & Bab y

F i g u r e 8 .2 T h r e e r e v e r s ib le im a g e s . T h e d o n k e y / s e a l im a g e w a s c r e a te d b y G.
H. F is h e r (1 9 6 8 ). T h e o ld - m a n / y o u n g - m a n im a g e , o r ig in a lly c a lle d " h u s b a n d a n d
f a t h e r - in - la w ;' w a s c r e a te d b y B o tw in ic k a n d p u b lis h e d in t h e A m e r i c a n J o u r n a l o f
P s y c h o lo g y in 196 1 . T h e m a n / w o m a n / b a b y im a g e w a s c r e a te d b y F is h e r (1967).

F IG U R E 8 .3 T h e I s le o f D o g s . A n 1 8 t h - c e n t u r y e n g r a v in g . U n k n o w n a rtis t.

ure em b ed d ed in th e pictures. G ive hints o n e at tim e until the

clients are ab le to perceive th e n ew figure. T he hints c o m e from the
s u b c o m p o n e n ts o f the picture i.e., "This part could b e seen as eith er
th e old w o m a n 's n o se or th e y o u n g w o m a n 's chin."
Perceptual Shifting: Transposing 221
/

W h ile sh o w in g the pictures explain to the clien t that th e perceptual

process o f tran sp o sin g o n e figure into th e o th e r is th e sam e as what
they m u st d o to c h a n g e a n eg ativ e b e lie f to a positive one. Have them
carefully m o n ito r h ow th ey are sw itching w h at th ey see in the draw­
ings. W e give th e exercise "How to Look at Things in New Ways" to all
clients to h elp th em use the techniqu e.

3. Next, draw a line o n a piece o f paper. (Both you and y o u r client

sh o u ld h av e paper in front o f you.) O n th e left side write all the
c o m p o n e n ts o f th e client's negative gestalt, o n e at a time. M a k e it
an e x h a u stiv e list. At th e b o tto m o f th e c o lu m n su m m a riz e all the
details o f th e old p ercep tion into o n e m a jo r them e.
4. O n th e right co lu m n , transpose each detail o f the old perception
into a m o re realistic, less dam agin g new perception. Discuss each
tra n sp o sitio n with th e client until you b o th agree that the n ew way
o f p e rce iv in g each detail is acceptable. At th e b o tto m o f the colum n,
ha v e th e client su m m a riz e all the subparts o f the new perceptions
in to o n e global, gestalt them e.
5. Have y o u r client practice tran sp osin g perceptions b y reading the
old w ay o f b e lie v in g and trying to tra n sp o se it into th e new gestal-
ten. C o n tin u e practicing until y o u r client can readily tran spose each
detail, and th eir total, from o n e view to th e other.
6. Have y o u r clients practice transposin g ever)' day until the new
gestalts form au to m a tically an d th ey have difficulty rem em b erin g
th e old perceptions.

E x a m p le 1: A m b ig u o u s-d ra irin g s h ift

In th e first d raw in g exam ple, th e old perception is o f an old w om an,
w h ile th e new gestalt is o f a y o u n g w o m an. T he tran sposition o f the
su b p a rts is:

O ld W om an Young W om an
tip o f nose tip o f chin
eye ear
m o u th neck band
wart o n nose nose
look in g at us look ing away
chin low er neck
h a ir o n n o se eyelash
222 T h e N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

H O W T O L O O K AT T H I N G S IN N E W W A Y S

The brain is an am azing living thing. It not o n ly accepts, stores,

and retrieves data, but it also dramatically tra n sfo rm s that data. It
g o e s far beyond th e information available an d creates a w h o le n e w
world. It takes raw bits of information an d transforms them into intri­
cate patterns, them es, a n d stories.
Our brain functions less like a com puter running a program than
like an artist painting pictures through w hich w e se e and feel and
touch the world. Our brain gathers various materials to paint; it takes
m ag en ta memories, mixes them with cyan em otions, gathers so m e
green from instincts, so m e brown, yellow, an d w hite from ou r senses.
It doesn't throw th ese colors randomly o n th e palette o f our mind; it
doesn't paint by th e numbers. It com p oses panoram ic scenes, dramas,
triumphs, and tragedies with its brush strokes.
Sometimes the pictures are m asterpieces o f creativity and im agina­
tion. The t h e o r ie s o f Albert Einstein, Thom as J e ffe r s o n , a n d J o h n Stu­
art Mill are as m uch works o f art as th e paintings o f Nicolas Poussin,
C la u d e Monet, and Vincent Van G ogh . Their brain s' creations can
enrich and en n o b le our lives, giving us n ew ways to perceive the
world w e live in.
Still o th er brains paint bizarre, disturbing portraits o f th e upsetting
sides of life. The philosopher Frederick Nietzsche a n d th e artist William
Blake create feelings o f horror in som e people. But w e n ee d to se e
even th ese views b ec a u se life has its disturbing aspects as well as its
enriching ones.
We are all artists. O ur paintings determ ine w h e th e r w e feel happy,
s a d , enraged, broken-hearted, or enraptured. The world doesn't cre­
a te our em otions our brain does. Sometimes our paintings are so
disturbing that they can overwhelm us. They can twist o u r lives s o
m uch that w e c a n n o t function effectively, a n d that is w h en counsel­
ing com es into play.
My j o b is to help you paint n ew pictures. It's not that you don't
know h o w to draw or that you paint b u n g led and b o tch e d pictures-
it's more that you m ay never have learned to draw your o w n pictures
You grew up trying to copy o th er peop les paintings, or, w o rse you
learned only to paint by th e numbers. As an adult y ou have tried to
pass th ese paintings off as your ow n. My j o b is n o t to tell you w h a t
to paint, but rather to g e t you to paint your o w n th em es based on
your ow n life experiences.
Maybe the best w ay to explain h o w our brain paints is to sh o w
you rather than tell you. I will sh ow you a reversible draw ing— a pic­
ture that contains tw o im ages d e p en d en t u p o n h o w y ou perceive it.
Perceptual Shifting: Transposing 223
/

It's a famous drawing that has been published many times— you may
have seen it before. A British magazine called Puck originally pub­
lished it in 1905 and called it “My wife and my mother-in-law."
Just as an experiment, take a look at the picture and try to see
both the young w om en and the old wom en. Practice until you can
see both clearly.

(Client practices with the therapist's help.)

W e see one image or the other because of our brain. It isn't just a
computer; it doesn't just add up the raw data in the picture; it trans­
forms the picture. I don't think any computer could transform this pic­
ture as well, but our brain can— instantaneously and automatically. It
takes the lines and shadows in the drawing and combines them with
our memories of similar drawings. It finds a theme— young wom an or
old woman.
But the most important thing to realize is that neither the old
wom an nor a young w om an is actually in the picture. The picture is
just a series of ink spots on a piece of paper— nothing more. W e may
see the young w om en or w e may see the old. Seeing one or the
other does not signify that w e are sick or stupid. Our brain creates
the image based on the tapestry of our ow n visual memories. The ink
spots are the canvas; our brain is the artist.
This drawing illustrates how our brain transforms all that w e see.
W e view the universe based on these transformations, including what
w e think of ourselves, h ow w e experience others, w hat w e deem as
good or bad, beautiful or ugly. W h at makes us laugh, cry, love, or
hate— all are based on the pictures our brains create.
W h a t brains w e have!
2 2 4 ---- _ _ ........ .. ......... T h e N ew H andbook oe C og nitive T h e r a p y T £ G m q u e s

E x a m p le 2 : K aren's C on ceptual S h ift

Karen c a m e to se e m e at the su gg estion o f h e r physician, w h o had
heard o f m y trea tm en t in h elp ing local athletes im p ro v e th eir skills.
S h e was a ch a m p io n racew alk er and was c o n c e r n e d a b o u t h e r deteri­
oratin g p e rfo rm a n ce in racew alk ing events. S h e had first b e c o m e
involved in th e sport a b o u t 8 years earlier and had m a d e rem a rk a b le
progress in regional and state co m p e titio n . But recen tly s h e had
b e c o m e increasingly a n x io u s im m ed iately b efo re each contest, an d as
a result h er p e rfo rm a n ce had b eg u n to deteriorate. S h e had b e e n dis­
qualified several tim es fo r "lifting o r b en t knee."
An analysis o f th e cogn itiv e c o m p o n e n t o f h e r a n x iety revealed a
person high in n e e d -a c h ie v e m e n t a n d perfectionism , a n d w ith a
severe dread o f failure. H er b ack g ro u n d sh ow ed th at h e r fath er had
con stan tly disapproved o f h er and c o n tin u a lly pressed h e r to succeed.
Despite early success in school, e c o n o m ic circu m sta n ces a n d an early
m arriage had prevented h e r from ach iev in g h e r full potential. As an
adult sh e felt that o th e r areas for a c h ie v e m e n t w ere closed to her, and
thus had taken up racewalking.
Table 8.1 depicts Karen's chart, rep resenting h e r old and new
gestalts.
Karen ev en tu ally transposed to the n ew gestalt. By c o n ce n tra tin g
o n shifting the subparts, sh e perceived th e n ew w ay o f lo o k in g at h e r­
self. Initially th e new gestalt was fleeting and s h e could o n ly se e it
occasionally. Gradually, th ro u g h practice, th e n ew p e rce p tio n b e c a m e
m o re p ro m in en t and th e old th e m e faded.

M eth o d 2. H idden I m a g e s
A n o th er type o f draw ing helps clients learn a slightly different typ e
o f transposition. Instead o f shifting from o n e im a g e to a n o th e r in a
drawing, clients lo o k for form in a picture w h ere n o form is im m e d i­
ately perceivable. Clinically it w ould b e eq u iv alen t to a client try in g to
find the m e an in g m a series o f Ijfe e x p e rie n ces that a re initially puz­
zling b u t later b e c o m e u nd erstan d ab le. A wife w h o keeps takin g back
le r a b u sin g hu sb an d , o r an alco h o lic w h o keeps flu n kin g o u t o f treat­
m en t program s m ay not im m ed iately b e ab le to m a k e se n se o f his or
her behavior. It is th e therapist's resp on sib ility to help th em find the
hidden meanings.

1. Select a g ro u p o f h id d en images.
2. Sh ow clients the im ages, starting with th e easiest and progressing
to the m ost difficult. 6
Perceptual Shifting: Transposing
/

T a b l e 8 .1
Chart o f Old and N ew Gestalts

O ld G e s t a lt N e w G e s ta lt

I m u s t b e v e r y s u c c e s s f u l; o t h e r ­ Su ccess, lo v e , re s p e c t, and ac­

w is e n o one w ill e v e r lo v e m e, c e p ta n c e are a ll b y p r o d u c ts of
a p p ro v e o f m e, o r a ccep t m e, and a c c e p tin g m y s e lf. T h e y m a y o r m a y
t h e n 1 w ill b e t o t a lly a lo n e . n o t c o m e , a n d m a y m e a n little in
th e m s e lv e s . U n le s s 1 a c c e p t th a t I
a m a g o o d , w o r th w h ile p e r s o n ju s t
th e w a y I a m 1 w ill n e v e r b e h ap p y .

Subparts S u b p a rts

T h e w o r s t t h in g in life is to fail. T h e w o r s t th in g in life is to b e

m o t iv a t e d s o le ly by' a fe a r o f fa il­
u re .

I f I d o n 't t o t a lly w in , I fail. I f I d o n 't w in I ju s t d o n ’t w in .

Su ccess is a n illu s io n ; f a ilu r e is S u c c e s s a n d fa ilu r e a r e b o t h illu ­

re a l. s io n s .

O n e m u s t b e in c o n t r o l o f e v e r y ­ M a n y t im e s o n e ju s t h a s t o le t life
th in g ( s e lf a n d e n v ir o n m e n t ) or happen. O ne c a n 't co n tro l m ost
o n e w ill fail. t h in g s in life.

I f I c a n ’t d o s o m e t h i n g p e r fe c tly , I I f s o m e t h in g is n o t w o r t h d o in g , it
s h o u ld n 't d o it a t a ll. is n o t w o r th d o in g w ell.

I a m r u n n in g o u t o f t im e t o s u c ­ S u c c e s s is ir r e le v a n t. T h e r e is n o
ceed . t im e lim it t o h a p p in e s s .

If 1 w o rry about fa ilin g , I'll be W o r r y in g d o e s n 't ch ang e any­

m o r e lik e ly t o s u c c e e d . t h in g ; it ju s t m a k e s m e fe e l b a d .

I m u st have ev ery b o d y resp ect I f 1 d id n 't r e s p e c t m y s e lf it w o u ld ­

a n d a p p r o v e o f m e. n 't m a tte r i f e v e r y o n e in t h e w o rld
r e s p e c te d m e.

3. Explain w h a t to lo o k for and w h ere they m ay find the im ages in the

drawing. Help the clients b y w orking with parts o f the images.
4. M a k e sure that y ou give clients e n o u g h tim e to find th e im age and
n o tic e th eir m e th o d o f searching.
5. After you h a v e h elp ed y o u r clients find the hidden im ages in the
pictures, sw itch to a discussion o f th eir cognitions. Use the drawings
 T h e N ew H an d boo k, oi C o g n it iv e T h e r a p y T e c h n iq u e s

as a g u id e an d h elp th e clients find th e h id d en m e a n in g in their

experiences.
6. To help them ingrain the new im ages into th eir aw areness, use the
follow ing procedures.

(a) Have th em tie the n ew b e lie f to a stro n g p erson al m em ory.

Cb) M a k e sure th e new co g n itio n is a g e n era l gestalt, not a su b ­
part.
(c) Clients shou ld m a k e the n ew t h e m e as sign ificant as possible,
b o th p ersonally a n d em otionally.
(d) Sim ple repetition o f seein g the new b e lie f is n o t effective. T he
clients m u st m en tally fill o u t th e n ew im a g e until it b e c o m e s
very m ean ingfu l personally.
(e) A lthou gh repetition doesn't in crease th e strength o f th e trans­
position, it does help clients r e m e m b e r th e tran sp o sitio n th a t has
b e e n made.

C om m en t
It is im p o rta n t that clients not feel ru shed du rin g th e transposition
exercises. E n cou rage them to relax an d take their time. Sin ce n ew per­
ceptions are often fleeting, it is also im p o rta n t th at clients practice
th eir tran sp osition s frequently.

F i g u r e 8 .4 H id d e n im a g e o f ^ la p o le o n a t h is t o m b in St. H e le n a , d r a w n b y
a n u n k n o w n a r tis t b e t w e e n 1821 a n d 1 8 3 6 , r e p r o d u c e d b y F e r n b e r g e r , 1950.'
Perceptual Shifting: Transposing 227
/

F IG U R E 8 .5 H id d e n im a g e o f C h r is t, d ra w n b y D o r o t h y A r c h b o ld a n d p u b ­
lis h e d b y P o rte r, 1 954.

T h e im ages are used in g ro u p cogn itive therapy as m u c h as in indi­

vidual sessions and can often b e m o re effective in the grou p process.
In grou p s th e im ages are sh o w n m ost forcibly with a desktop c o m ­
puter. Using presen tation softw are so th a t the im ages can b e projected
o n to a screen or a large external monitor, the therapist can use the
d esktop m o u s e to identify and ou tlin e the images. S o m e action pro­
g ra m s allow th e im ag e to em e rg e from its background.
The great ad v an ta g e o f u sing tran sp osin g in a grou p is th at clients
w h o se e th e im ag e can help th ose w h o can't. G roup transpositions
teach clients h ow to give and receive aid from others— a lesson that
clients need in o rd e r to learn to c h a n g e th eir ow n beliefs.
Each tim e you use th e im ages in grou p therapy, ask the group not
o n ly to help each o th e r to se e the images, b u t also, and far m ore
im portantly, to d ev elo p a list o f rules or guidelines to use w h ile m a k ­
ing transpositions.
O v e r the years w e have used the draw ings with h u ndred s o f groups
in a great variety o f clinical populations. Table 8.2 lists th e m ost c o m ­
m o n rules g ro u p therapy clients h av e developed.

F u rther In fo r m a tio n
M o r e reversal and e m b e d d e d pictures can b e found in Attneave
(1968), Berger (1977), Block an d Yuker (1989), Boring (1930), D allenbach
(1951), W. Ellis (1939), Fernberger (1950), Fisher (1967, 1968), Gregor)'
228 T he N ew H a n d bo o k or C o g n it iv e T h e r a p y T e c h n iq u e s

T a b l e 8 .2
Transformation Rules*

To c h a n g e w h a t y o u see T o c h a n g e w h a t y o u b e lie v e _____________

K n o w w h a t im a g e y o u a r e lo o k in g K n o w w h a t a t t it u d e y o u a r e t r y ­
for. in g t o g e t y o u r s e lf to b e lie v e .

A c c e p t h e lp fr o m so m eon e w ho L iste n to y o u r th e ra p is t, w h o se e s
s e e s t h e im a g e . a n d u n d e r s ta n d s th e n e w c o g n itio n .

T a k e a ll t h e tim e y o u n e e d t o fin d D o n 't e x p e c t t o g e t t h e t h e r a p is t's

t h e im a g e . m e a n in g im m e d ia te ly .

L o o k f o r it! Look f o r it! D o n 't ju s t p a s s iv e ly

h o p e t h a t o n e d a y y o u w ill w a k e
u p b e li e v i n g t h e n e w th o u g h t .

K e e p t r y in g a n d d o n 't g iv e up. K e e p try in g . It m a y t a k e m o n t h s to

t r a n s p o s e a b e lie f.

I f y o u c a n 't s e e t h e w h o le im a g e , I f y o u c a n 't a c c e p t t h e t o ta l b e lie f ,

try t o s e e p a r t o f it. t r y t o a c c e p t p a r t o f it.

W h e n y o u fo r g e t w h a t y o u saw , g o W h e n y o u r n e w b e l i e f s h ift s b a c k
b a c k a n d try t o s e e it a g a in . t o y o u r o ld o n e , f o llo w t h e t e c h ­
n iq u e s a g a in u n t il y o u b e li e v e it.

K e e p p r a c tic in g s e e in g t h e im a g e s K eep p r a c t ic in g th e new b e lie f

u n til t h e y b e c o m e s e c o n d n a tu r e , u n t il it b e c o m e s h a b i t u a l a n d y o u
so th a t you s p o n ta n e o u s ly and h a v e d iffic u lty r e c a llin g th e o ld
a u t o m a t ic a lly s e e th e m . b e lie f.

* S e e t h e d is c u s s io n o f q u a n t u m le a p s in t h e s e c tio n o n d iffic u lt tr a n s p o s itio n s f o r m o r e d e t a ils a b o u t

th e s e ru les.

(1977), Joyce (1994), M a c h (1959), M artin (1914), N ew hall (1952), W ever

(1927). O n e o f th e b est sou rces is th e w o rk o f M. C. Escher (1971).

D if fic u l t T r a n s p o s it io n s

Principles

I h ere is o n e great difficulty w ith th e previou s te c h n iq u e s— th e

im ages are to o easy for m a n y clients. S o m e clients will see th e im ages
Perceptual. Shifting: Transposing 22.9
/

im m e d ia tely w h ile others m ay take five or ten m in u tes to find them.

But h elp in g clients to c h a n g e th eir ow n beliefs is far m ore difficult. It
m a y ta k e clients m o n th s o r ev en years to m a k e a m a jo r cognitive shift,
so ev en th o u g h they are qu ite willing to sp end 10 to 15 m inutes lo o k ­
ing for a n ew image, th ey m a y b e q u ite unw illing to spen d several
m o n th s lo o k in g for a new thought.
To a p p roach th e difficulty level o f c h a n g in g an attitude, m o re diffi­
cult draw ings m ust b e em ployed. T hese drawings require clients to
sp e n d m o re tim e and effort in finding th e image, thus b etter approx­
im a tin g th eir effort in c h a n g in g beliefs.

M eth od
1. S h o w clients o n e o f th e im ages in figures 8.6, 8.7, 8.8, or 8.9, or pick
o n e o f y o u r own.
2. Explain to y o u r clients that th e drawings are like their beliefs. Try­
ing to see th e rational th ou g h t in their lives is like trying to m ake
se n se o u t o f th e drawings.
3. T h e m ost im p o rta n t part o f th e exercise is to m o n ito r h ow th e client
h a n d les th e frustration o f n o t b e in g ab le to find the images, (par­
ticularly figure 8.6— th e cow). Do they get discouraged an d give up?
Do they b e c o m e an g ry w ith you for show ing th em th e picture? Do
th e y refuse to try further? Do th e y c o n d e m n them selves for not
finding it? Do th ey claim th a t you are w ron g and that th ere is no
im a g e to b e found?
4. W h ile clients are d o in g th e task, instruct them to report any and all
s tr e a m -o f-c o n s c io u s th ou g h ts and feelings. W rite dow n all c o m ­
m e n ts and y o u r o b serv a tio n s o f the clients' b eh a v io rs as they
search fo r th e image.
5. Tell clients th a t th eir frustrations, self-anger, or feelings o f inferior­
ity a b o u t this task are likely to b e th e sam e feelings and thoughts
they will h av e w h e n w o rk in g o n their cognitions. Discuss th e rela­
tionships b etw e en the tw o in detail. A ny problem s clients have
w h e n lo o k in g for th e difficult im ages will m ultiply w h en th ey try
to c h a n g e th eir beliefs. Thus, if th ey give up o n the drawings or get
a n g ry with you, they are likely to do the sa m e with th eir beliefs.
6. Help you r clients solve these problem s so that they successfully com ­
plete the task. If they are too tense, teach them relaxation while doing
th e exercise; if th ey are self-condem ning, help them counter the
beliefs; if they wish to give up, en cou rag e th em to continue. In any
case, sustain y o u r help until they can do the exercises successfully.
230. T h e N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

F i g u r e 8.6 C o n c e a le d cow . D ra w n b y L e o P o t is h m a n a n d p u b lis h e d b y D a l-

le n b a c h , 195 1 .

F i g u r e 8 .7 C a n y o u t r u s t th is m a n ? T h e a n s w e r is w r itt e n a ll o v e r h is f a c e
(S e e f u r t h e r in f o r m a t io n f o r a n s w e r a n d r e fe r e n c e .)
 Perceptual Shifting: Transposing 231
/

%
F IG U R E 8.8 W h a t is th is ? (S e e fu r th e r in fo r m a t io n fo r a n s w e r a n d re fe r e n c e .)

F IG U R E 8.9
A-
T h is w o r d c a n b e r e a d in t h r e e la n g u a g e s : E n g lish , C h in e s e , o r
J a p a n e s e . It n a m e s a city . ( S e e f u r t h e r in f o r m a t io n fo r a n s w e r a n d re fe r e n c e .)
 T h e N e w H a n d bo o k, of C o g n it iv e T h e r a p y T e c h n iq u e s

7. Show the clients that the techniques they used in solving th e draw­
ing puzzles are th e sam e that they can use to transpose th eir beliefs.
List each correction and have them record th em for further reference.

E x a m p le 1: The Story o f th e D raw in gs

S o m e readers may b e interested in th e story b e h in d m y u se o f
images to teach perceptual shifting. T h e story m a y also ex p lain w h y I
find im ages so central to cogn itive restructuring therapy.

Q u a n tu m Leaps
For so m e tim e I had noticed that cogn itiv e c h a n g e w as difficult for
a lm ost all clients; it to o k a great deal o f effort, and m a n y clients found
it easier to sim p ly c o n tin u e in th e sam e old w ay o f th in k in g rather
t h a n put in th e effort to see s o m e th in g new. Still, so m e learned new
skills, tried n ew experiences, shifted their attitudes.
These ch an g es gen erally occu rred at a very slow pace. W h e th e r the
client was learning to b e assertive, w o rk in g on guilt, m a ste rin g a n x i­
ety, or b u ild in g a successful m arriage, years o f practice a n d w o rk w ere
required. Like in m o u n ta in clim bing, m ost clients slow ly w o rk ed their
w ay from o n e rocky crag to another, o n ly grad ually c lim b in g up th e
precipice. If th ey reached th e top, th ey had a clea rer view an d felt
stronger for having m a d e it. O th er clients gav e up halfway, lackin g the
p atien ce or e n d u ra n c e required to reach their goal.
W h ile the o v e rw h e lm in g m ajo rity o f clients followed this pattern,
s o m e clients m a d e d ra m a tic changes. In a few days tim e th e y ch an ged
a way o f th in k in g th a t th ey had held for m ost o f th eir lives. It w as as
if w h ile c lim b in g the m o u n ta in th e y su d d en ly ju m p e d to th e s u m ­
mit— m ak in g a q u a n tu m leap.
T hese leaps fascinated me. How could clients w h o had b elie v ed th e
sa m e n o n se n se for 3 0 years su dd en ly stop b e lie v in g in it at all? How
c o u ld th ey h av e ch a n g ed in a few days or h ou rs w h a t had ta k en a life­
tim e to build? W h at w ere the principles b e h in d th e se leaps?
I first ob serv ed th ese q u a n tu m leaps w h en I was a stu d e n t at a
so u th ern university. O n e Satu rd ay a ftern o o n a ten t revival m eetin g
w as held out in the countryside, not to o far from the cam p u s. H aving
the a ftern o o n free an d b e in g curious, I decided to go.
In an o p e n field I fou n d a large c a n v a s tent sh eltering fo u r h u n d red
folding chairs. It was as hot a n d steam y as a sau na, an d p e o p le m e a n ­
dered into th e seats from all^sides. A lo n g -h a ir e d p re a ch e r was in th e
front, ran tin g and raving a b o u t the h o rro rs o f hell a n d d e scrib in g h ow
 Perceptual Shifting: Transposing
/ 233

it w o u ld feel to b e b u r n t by flam es forever— h ow th e pain, the stench

o f b u r n in g flesh, an d th e w ailing w ould overw helm us.
The people in attendance appeared to be farmers; they wore overalls
and looked like they had just finished plowing their fields. At first I did­
n't see a n y b o d y there from the university; this wasn't the kind o f service
students were likely to attend. But then I spotted Roy a you ng freshman
w h o had visited m e at the student counseling center for o n e session. He
was a local b o y attending school on a football scholarship and majoring
in P.E., and he'd b een sent to see m e because h e had a severe drug prob­
lem. He drank heavily, and his d orm adviser worried that he'd b e thrown
o ff the team and expelled from school. It had b een clear in the o n e ses­
sion that he'd attended that he didn't really want to stop.
Roy and the o th ers listened to th e p re a ch e r describe all th e horrors
of hell; he h a ra n g u e d th em for an hour, and th e p eople w ere getting
m o re a n d m o r e upset. S o m e m o an ed and cried out, "Save me!'' Others
s to o d up shrieking. T he preacher's description reached a crescendo,
and h e said, "This is th e place G od has prepared for liars (audience
m oaned), u n believ ers (m oan), hippies (hiss); w inos and drugees (m oan
and hiss), fornicators (bigger m oan); adulterators (biggest moan)." Then
su d d en ly th e preach er w arned that in ord er to keep out o f th e eternal
fires o f d a m n a tio n they m u s t re n o u n c e the devil an d c o m e to Jesus
now. "W alk right up to th e front o f th e tent and stand w ith Jesus." A
little old lady w alked up first, crying and w aving her arms. Then
another, then th e aisles w e re filled w ith p eople w alkin g to th e front,
m o a n in g an d w aving their h and s an d crying out, "Save m e Jesus." I
noticed that R oy w en t up with the rest.
T h e p re a ch e r th anked Jesus for saving th ese sinners, an d then he
d escribed in great detail w h at heaven was like. He said that in h eav en
w e w ould g a th e r w ith all o f o u r friends and relatives w h o had g o n e
to Jesus, that all o u r physical infirm ities would be w ashed away. We
w ould b e forever young, w e would talk with the prophets, w e would
b e so o th e d a n d co m fo rted in th e arm s o f the Jesus. He w ent on for a
w h ile like this, then the p eople sa n g so m e h y m n s (alm ost ev eryb od y
sang) an d th e revival ended.
I saw Roy o n ca m p u s a few m o n th s later and asked h im how he
w as doing. He said h e had stopped drinking an d using drugs, h e had
m a d e th e football team a n d was doing fairly well in school. T he sev­
eral o th e r tim es I saw Roy h e told m e th e sam e thing. He con tinued
to d o well, stayed clea r o f drugs and drinking, and was still on the
football team. Roy had m a d e a q u a n tu m leap, all b e c a u s e o f th at after­
n o o n at the tent revival m eeting.
 T h e N ew H a n d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

O ver th e years I h av e ob serv ed o th e r q u a n tu m leaps. T h o u g h m ost

clients struggled and plodded, m a k in g ch a n g es in slow, m in u te steps,
th ere w ere still a b o u t 10 p ercen t w h o had m a d e d ra m a tic changes.
I had n e v e r u n d erstoo d h ow s o m e p eople could m a k e th e se shifts
until a c h a n c e e x p e rie n c e at a university library. I was research in g
s o m e articles for a b o o k and th u m b in g th ro u g h an old G e rm a n psy­
ch o lo g y jo u rn a l in w h ich I noticed an article a b o u t hidden images.
O n e particular drawing, cap tion ed as a sketch o f a cow, ca u g h t m y
attention. To m e it look ed like a m ass o f m e a n in g less b lotch es, a n d I
pushed it away. A few w eek s later 1 retu rned to the s a m e library an d
w as look in g in th e s a m e jo u rn al. 1 saw th e cow picture again but still
didn't see the cow. I thou ght, "Stupid picture. T h ere is n o cow!" I
pushed the article to the side and w o rk ed o n s o m e th in g else. But right
b e fo re I left the library, 1 glan ced o v e r at th e picture sitting o n th e side
o f the desk a n d th e im ag e em erged — th e h ead an d forequ arters o f a
cow. T he shift was not grad ual; it occu rred su dd en ly— a visual m e ta ­
m orphosis, a perceptual q u a n tu m leap.
I im m ed iately th ou g h t o f Roy. He had also seen s o m e th in g su d­
denly. Could it b e that seein g an im age pop up in a draw ing is the
s a m e as h avin g a new attitude p op up in o u r b rain s? T h o u g h o n e is a
p ercep tion w h ile th e o th e r is a con cep tion , if therapists co u ld figure
out h ow an im age su dd enly leaps out in th e se draw ings, th en m a y b e
w e could discover h ow s o m e clients m a k e q u a n tu m leaps.
O ver th e years I have collected so m a n y ream s o f th ese pictures for
study th a t it has alm ost b e c o m e em barrassing. C olleagues m u st think
twice a b o u t h aving m e a p p e ar on a panel or w o rk sh o p — "If w e invite
Dr. M e M ullin, h e m ay show his d a m n pictures again." Still, th ese pic­
tures are the b est a n a lo g y I have found to ex p la in a c o m p le x princi­
ple o f psycholog}' T h ey are m y Rosetta s to n e to u n d ersta n d in g
cognitive c h a n g e an d grow th. I b e lie v e they e x p la in h ow clients m ak e
q u a n tu m leaps.
W h e n clients lo o k at th e cow, what d o th ey see? M o st d o n 't see the
cow im m ediately. In fact very few do. If they don't, it d o esn 't surprise
me. This is o n e o f th e m ost difficult pictures in m y portfolio, a n d it
takes tim e (often weeks) b e fo re the co w em erges. Clients se e th e cow
w h en their brain s are ready.
But w hat is m o re interesting th a n th e a m o u n t o f tim e it takes for
clients to se e I h e co w is th e process the clients g o throu g h. How are
t h e y su d d en ly ab le to see s o m e th in g that they h a d n 't b e e n a b le to see
at all? T he draw ing d o esn 't ^hange; it r e m a in s th e s a m e w h e th e r they
see th e co w or not. T he im age on their retinas is th e sam e. T heir optic
 Perceptual Shifting; Transposing

n erv e a n d th e in fo rm a tio n reach in g the occipital area o f their brains

a re n ot changed . T h e o n ly difference is in w h a t their brain does after
this— th e w ay their b ra in organizes th e raw data. T h e splotches o n the
p a p er rem ain m e a n in g less blotches o r tu rn into a cow. W h e n they
im a g e a cow, it is b e c a u s e their brains h av e m ad e a transform ation.
O n ly th e ir brains ca u se the q u a n tu m leaps.
W h a t co u n ts a b o u t th e exercise is n ot w h e th e r o n e sees the cow or
not, b u t th e set o f rules w e use to discern and co m p reh en d things.
I low are o u r brain s ab le to create th e cow ? W h at principles lie b eh in d
th e tran sition fro m seein g n o th in g to seeing som eth in g? W h a t m e th ­
od s d o clients use?
W h e n I ask m y clients how th ey are ab le to see th e cow, so m e
a n sw e r quickly. They say it is easy; all you do is look at this o r that
part o f th e picture and th e cow em erges. If you inspect th e left you
n o tic e part o f the cow's right ear; n e a r the b o tto m is th e nose; about
in the m iddle is th e cow's left eye.
D espite th e ap p a ren t logic o f this view, I do n o t th in k it is accurate.
It's n o t w h ere the clients look, but w h a t their b ra in s d o w ith w hat they
see. Clients c a n stare at ju st o n e spot in th e draw ing and still recog­
nize th e co w w ith o u t altering th eir focal point.
T h e w a y clients' b ra in s g e n erate a cow in th e draw ing is th e sam e
w ay their b rain s m ak e q u a n tu m leaps. T he picture is th e key. W h at is
tru e for th e picture is true fo r th eir attitudes. In m y w ork with clients
I h av e discovered five elem en ts th a t seem essential b o th for seeing
h id d en im ages in draw ings and ch an gin g lo n g -h e ld beliefs. These
principles are at the h ea rt o f all q u a n tu m leaps: willingness, guidance,
flexibility, time, and repetition.

W illingness
T he first elem ent, willingness, refers to th e fact that clients m ust be
m otivated en o u g h to lo o k at things in a new way. If they dogm atically
a n d rigidly hold to their old view point, th ere is n o ro o m for new atti­
tudes. If th e y lo o k at th e picture and see n othing, then rigidly insist
th at th ere is n o th in g to see, no o th e r way o f look in g at it, th ey will
n e v e r se e th e cow.
T h e s a m e princip le is true for beliefs. I f clients are absolu tely sure
th ey are right and they allow for n o possibility o f b ein g wrong, they
w'ill n e v e r c h a n g e w h a t they think. O n e client I en co u n tered was
a b so lu te ly su re h e was a weak, passive, w im py person. He always tried
to c o m p e n s a te b y acting to u g h and m e a n — th e sh ort m an syndrom e.
T h e tru th was that h e w asn 't w h a t h e thought. He was n eith er w eak
236 T h f. N e w H a n d b o o k o i- C o g n it iv e T h e r a p y T e c h n iq u e s

n o r passive— in fact, h e w a s ‘ far to o aggressive an d violen t. But

b e c a u s e o f his p ercep tio n h e c o n tin u e d trying to m a k e h im s e lf
to u g h er an d meaner. He forced h im s e lf to th e p oint w h ere h e b e c a m e
so o b n o x io u s that n o o n e w an ted to b e a r o u n d him ; h e was fired from
jo b s and lost his girlfriends.
W h e n h e was sh o w n his m istak en self-p ercep tion , h e refused to lis­
ten. He d ogm atically rejected th e possibility th a t h e co u ld b e w rong,
and refused to accept that th ere could b e a n o th e r w ay o f lo o k in g at
himself. He n ev er changed , still can't hold a jo b , an d has n o friends or
in tim ate relationships b e c a u s e o f his h y p er-ag gressiven ess.

G u id an ce
T h e se co n d principle b e h in d q u a n tu m leaps is gu id ance. To see
so m eth in g new, it helps to h av e s o m e o n e w h o has alread y se e n the
n ew v ie w p o in t act as a guide. T h e b est co a ch e s are th e m e m b e r s in
g ro u p therapy w h o h av e already m ad e q u a n tu m leaps. T h ey kn ow
exactly w h a t to lo o k for and can gu ide th e others. It is easier to find
the cow w h en told to lo o k for a cow ; if clients th in k th ey are lo o k in g
fo r a m eridian o f longitu de th ey will b e lo o k in g forever.
Similarly, s o m e o n e w h o believes th e new attitu d e is b e tte r ab le to
tea ch others to see it. This m a y ex p la in w h y se lf-h e lp g ro u p s like
A lcoh olic A n o n y m o u s, R ecovery Inc., T he N ational A lliance for the
M en tally 111, etc., are so helpful to clients. C o ca in e addicts b e n e fit from
listening to recovering addicts, a g o rap h o b ics learn from p e o p le w h o
h av e o v e rco m e their panics, p eople suffering from g r ie f find survivors'
grou p s helpful. All o f th e se recovering p e o p le h av e alread y m a d e their
q u a n tu m leaps, and are a b le to sh ow th e b e g in n in g clien t th e way.

Flexibility
T h e third principle is flexibility. Clients n eed to a ttem p t different
strategies in ord er to m a k e a p erceptual leap. To see th e cow th ey m a y
lo o k at different parts o f th e drawing, o r b rin g th e picture close to
th eir eyes, o r m ov e it farther away. Perhaps th e y need to put th e pic­
ture aside for a w hile a n d th en lo o k at it later. O n e w ay o r another,
they need to vary th eir strategy rath er t h a n c o n tin u in g to try th e s a m e
m ethod.
This s a m e prem ise hold s true fo r beliefs. To c h a n g e an attitude,
clients n eed to lo o k at their beliefs in n ew w ays until th e shift takes
place. Clients w h o keep a ttem p tin g to d o th e s a m e th in g o v er a n d over
again n ev er change. Clients w h o d o shift u se different strategies. T hey
m a k e th e old attitude w eaker and inject streng th into th e n ew one.
 Perceptual Shifting: Transposing 237
/

S o m e m a y tie th e new b e lie f into s o m e powerful, person al m em ory

that is e m o tio n a lly intense. S o m e will rein force them selves w h en ev er
th ey p erceiv e th e n ew b e lie f a n d punish th em selves w h en they detect
th e old. S o m e divide their beliefs into parts and shift the parts before
they w o rk in g o n th e ir total gestalt. W h a t is im p o rta n t is that they all
c o n c o c te d so m e strategy, so m e new system to shift their cognitions.

T im e
T h e fo u rth principle is time. C h anging clients' view p o in ts will take
time. T h eir b rain s need tim e to process th e in form ation until a new
p ercep tio n co m es together. If they stop look in g for th e co w after only
a few se co n d s th ey will n ev er see it.
The sa m e principle is true for c h a n g in g their beliefs, philosophies,
o r attitudes. It m a y requ ire o n ly a few m inu tes to shift the im age in a
picture, b u t it takes m o n th s o r years to c h a n g e a philosophy. No m at­
ter h ow lon g it takes, it is im p o rta n t for clients to c o n tin u e to w o rk at
th e change. O therw ise th ey will n ev er b e ab le to m ak e the q u a n tu m
leap. T he b ra in m akes th e shift w h en they are ready, a m o m e n t m an y
clients h av e described as an "Aha" exp erien ce: "O n e m o rn in g I w oke
up to an 'aha'. I could see it. I could see w h a t I had b e e n w orking
tow ards fo r all th ese weeks." I h e perception they had b e e n searching
for su d d en ly ap p eared — th eir brains snapped ev eryth in g togeth er in a
clear, powerful, certain image. They m a d e their q u a n tu m leap.

R e p etitio n
T h e fifth an d final principle is repetition. O n e o f th e u n fortun ate
aspects a b o u t q u a n tu m leaps is th a t ev en after clients have trans­
form ed th e way they lo o k at them selves, th e y often leap back. The cow
picture again illustrates th e process. If th e y put th e picture aside and
th en lo o k at it again later, th ey will o n ly see the m ean ingless blotches
ra th e r th a n th e cow. Similarly, th ou gh th ey m ay feel excited and
h a p p y a b o u t having ch an ged th eir attitudes, a few weeks later they
m a y w a k e up th in k in g th e sa m e old b e lie f again. At this point I reas­
sure th e clients th a t n o th in g terrible has h app ened . "After th inking in
a certain w ay for 2 0 years, it is n o t surprising that y o u r brain shifted
b a ck to the old way w h e n e v e r it is given it h a lf a chance."
T he so lu tio n for th ese backw ard leaps is th e sa m e as for th e draw­
ings— practice! I f clients w an t to see the cow ev ery tim e they lo o k at
th e drawing, th ey m u st keep o n practicing. After a tim e th ey find it
m o re and m o re difficult n ot to see th e cow. Likewise, if they keep
retreatin g to their old cognitions, th ey need to keep practicing seeing
238 T h e N ew H a n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

th e new belief. M a n y clients h av e to m a k e th e s a m e leap rep ea ted ly

until it b e c o m e s perm anent.
I b e lie v e it is p ossib le to c h a n g e alm ost a n y attitude, belief, value,
o p in io n or even a n y p reju d ice using the a b o v e principles. Like Roy,
m ost clients are n ot truly stu ck w ith a n y o f th e ir old attitudes, n o m at­
ter h ow ingrained. No m atter h ow deep the roots are o r h o w a n cien t
th eir origins, c h a n g e is possible.

E x a m p le 2 : T he Story o f Terry
Terry was referred to m e b y a n o th e r cogn itiv e therapist w h o m sh e
had b e e n seein g for a b o u t fou r m o n th s a b o u t a relation sh ip problem .
T h e therapy had b e e n helpful for the relation sh ip b u t had not b e e n
b eneficial in reducing h er constan t, lo w -lev el anxiety. A fter o u r in take
sessions, it was clear that sh e was a so cia l phobic. S h e w'as afraid o f
b e in g scrutinized b y o th ers an d w orried a b o u t d o in g th in gs that o th ­
ers w ould co n sid er sham eful. Sh e avoided p u b lic e x p o s u re w h e n e v e r
possible.
W e followed the traditional cogn itiv e restructuring a p p roach , and
she m ad e g o o d progress, b u t w h e n w e started u sing th e tran sp osition
tech n iqu e, s h e had difficulties. S h e was d oin g her h o m e w o r k (at least
o n e h a lf-h o u r o f practice a day), b u t sh e rep orted that sh e w a sn 't ab le
to shift h er thoughts. W e decided th a t th e "difficult pictures" m ig h t
give us so m e clues as to h ow sh e m ight b e sa b o ta g in g h e r o w n efforts
to transpose her beliefs.
The follow ing is a transcript o f part o f th e session w h ere th e diffi­
cult tran sp osition a p p roach was used.

THERAPIST: I am g o in g to sh ow you so m e m o re draw ings. Th ese

are sim ilar to th e o n es I show ed you before, b u t th e y are a little
m o re difficult. This time, I w ould like you to d o s o m e th in g sp e ­
cial w h ile look in g for the images. Please tell m e w h a t y ou are
feeling and w h a t you are say ing to y o u rse lf d u rin g th e exercise.
M ost o f the tim e p e o p le d o n 't tell us th e ir e m o tio n s o r thou gh ts.
T h ey b lo c k them out. But fo r this exercise 1 w a n t y o u to focus
and report o n these a u to m a tic th o u g h ts and feelings ju st as you
e x p e rie n ce them . Do you agree? Look at this picture. Do y o u see
an yth in g ? Take all the lim e you need.
TERRY: This looks tough. . . . I'm n ot sure I can d o it. I d o n 't se e it
at all— are y o u sure it's there? . . . Is it th e s a m e size o r d o I have
to tu rn it? I d o n 't like* d o in g this— I can't d o it. . . . I a lm o st had
 Perceptual Shifting: Transposing
/

it. . . . Nope, it's g o n e again. This is silly! 1 d o n 't see w h y I h av e to

do this. It's a d u m b exercise. I really want to stop.

(T h rou g h ou t th e exercise I en co u rag ed h er to continue.)

TERRY: I'm n o t sm a rt e n o u g h to do this. M a y b e y o u r o th e r clients

are brighter. . . . This isn't g o in g to w o rk for me. I see w h ere it is
su p p osed to b e b u t I c an 't see it.

(The a b o v e rem ark s covered a p erio d o f a b o u t 10 m inutes. During this

tim e Terry b e c a m e in creasin g ly agitated. Sh e started to push h erself
h a rd er and h a rd er to see th e form.)

TERRY: It's n o good. I can't d o a n y th in g right. You m u st th in k I'm

really stupid. Do a n y o f y o u r o th e r clients take this long to see
it?

(After a few m o r e m in u tes during w h ich Terry m ad e sim ilar remarks,

I decid ed to intervene.)

THERAPIST: Okay. Stop for a m o m e n t an d let's talk a b o u t it. Do you

n o tic e that w h at you are th in k in g and feeling w hile doing the
e x ercise is sim ilar to w hat you th in k an d feel w h en you are at
h o m e trying to c h a n g e you r beliefs?
TERRY: Yes! I h a v e tro u b le with that too.
TH ERA PIST: Well, let's an alyze w h a t you are th in k in g and feeling.
In fact, I would app reciate it i f you would write it down. First, you
told y o u rse lf it was tough, a n d that you p ro b a b ly could n't d o it.
N ext you attacked y o u rse lf for not seeing it by calling yourself
stupid. T h en you w orried a b o u t w h a t I would th in k o f you for
n o t se ein g it, and finally you g o t a n g ry at m e for giving you the
exercise. Is m y sum m ar}' accurate?
TERRY: I'm not sure.

(We h a d recorded the session, a n d I had Terr}' listen to her rem arks on
th e tape.)

TERRY: Yeah! I sure did attack myself]

THERAPIST: Yes you did! And did you n otice that you were getting
m o re a n d m o re a n x io u s the h a rd er you tried, and the m o re you
attacked?
TERRY: Sure, I was getting pretty nervous.
THERAPIST: Okay, let's try so m e th in g different this time. You
noticed th at th e m o re y ou attacked yourself, the less you were
 T h e N e w H an d bo o k oe C o g n it iv e I h era ey T e c h n iq u e s

a b le to c o n c e n tra te o n th e task. Well, let's try to c h a n g e th in g s a

bit. This tim e I w ant you to lo o k at th e pictures in a v ery relax ed
way. W e will practice b y g o in g b a c k a n d d o in g so m e relaxation
exercises w e did a few sessions ago. W h e n e v e r y ou start feeling
tense, 1 w ant y ou to stop w h a t y ou are doing, ta k e a d eep breath,
and relax y o u r m uscles in th e w ay I h a v e sh o w n you. In addi­
tion, w h e n e v e r y ou start th in k in g those se lf-a tta ck in g thou gh ts,
I w a n t you to qu ietly say, "Stop, calm , relax," and th e n im m e d i­
ately c o n ce n tra te o n th e task again. W h e n e v e r y o u r m in d w a n ­
ders in a n y w ay from th e task, stop th e th in k in g a n d retu rn again
to seeing th e picture. Instead o f pressuring y o u rse lf to se e the
pictures, I w ant you to relax a n d ju st let th e picture com e. Do you
u nderstand?

(We practiced the relaxation for a b o u t 15 m inutes. Then sh e returned

to look in g at the pictures. W h e n e v e r sh e appeared to te n se up, I told
her to relax. If sh e started to frown I told h e r to stop th e th o u g h t and
calm ly return to th e task w ithout pressuring herself, to just w ait an d let
the picture c o m e o n its ow n accord. After a b o u t tw o m in u te s sh e could
see th e form and show ed m e b y draw ing it w ith h e r finger. W e th en
did two m ore drawings and sh e got th em b o th in less than a m inute.)

THERAPIST: All right, I th in k w e learn ed so m e th in g here. It's p r o b ­

ably the rea so n you h a v e had difficulty d o in g th e tran sp osition s
at h om e. W h e n you p u sh y o u rse lf to see so m eth in g , it ju st m akes
y ou m o re tense, you start criticizing yourself, an d you are less
likely to see it. W h a t you did h ere is p ro b a b ly w h a t y o u n ee d to
d o at hom e. So I w o u ld like y ou to start practicing relaxing, do
the "stop, calm , relax tech n iq u e, an d let th e tra n sp o sitio n s c o m e
instead o f tryin g to m a k e th em appear.

C om m en t
If th e clien t finds the reversible or h id d en figures to o easily, th e
therapist m ay need m o re difficult draw ings th a n th e o n e s presented.
In these cases y ou m ay find it helpful to sh ow y o u r clients a n y o n e o f
the m a n y 5 -D illustrations available. In m ost cases clients o n ly see th e
2 -D versions. Explain that th e re is a 3 - D im ag e that is v isib le if they
will follow y o u r instru ctions an d practice lo o k in g for it. U se a n y o n e
o f th e teaching m e th o d s available— H orib uchi (1994a, pp. 10, 9 0 -9 4 ) is
particularly helpful.
Be sure to tell clients that th ere are tw o te c h n iq u e s w ith w h ic h to
Perceptual Shifting: Transposing 241

see the im ages— parallel an d c ro ss-ey ed — and that each m e th o d

reveals a different image. Help clients practice until th ey can see the
im age, a n d tell them that th ey will n eed to follow th e sam e process to
find th e new beliefs.
3 -D im ages b e tte r e m p lo y the practice effect than reversible draw­
ings. T h e m o re 3 -D im ages y o u r patients can find, th e b etter ab le they
a rc to see c o m p le te ly n ew images. Likewise, you can tell you r clients
th a t th e m o re th ey practice, th e m ore effectively and easily th ey can
c h a n g e their beliefs.

F u rther In fo r m a tio n
Figure 8.7 You c a n n o t trust this m an ! If you tu rn the b o o k 65
d egrees to th e left, you will see his face spells o u t the word "liar'' Pic­
tu re is co u rtesy o f Paul Agule (B look & Yuker, 1989).
Figure 8.8 This is a m a p o f th e M ed iterran ean Sea (Block & Yuker,
1989).
Figure 8.9 T h e city is "Tokyo." It can b e seen b y tu rn in g th e b o o k 90
degrees to th e right. Picture cou rtesy o f David M o se r (Block & Yuker,
1989).
C lien ts h a v e fo u n d th e fo llo w in g 3 - D im a g es m ost useful:
H o rib u ch i (1994a, 1994b) provides an interesting history o f stereogram
a lo n g with s o m e im ag in ativ e pictures. M agic Eye (1994a, 1994b) has the
m ost readily a v a ila b le drawings. A nderson (1994) provides several
series o f illusions. T h ey are inexpensive, so you r clients can b u y them
and practice se ein g th e images at h om e. W orsick (1994) has written an
in teractive s to r y b o o k w ith 3-D illustrations, and R u m o r (1994) pro­
vides a vid eo w ith over 100 images th at will provide th e client with
ex ten siv e practice.

P r o g r e s s iv e Im ag e M o d ific a t io n

Principles

For m a n y clients there is a h u ge gap b etw een th eir old irrational

b e lie f a n d the new m o re useful belief. T he gap m a y b e so large th at
th e clients find it a lm ost im p o ssib le to leap from o n e to th e other. In
su ch cases th e therapist teaches clients to m ak e smaller, m ore gradual
c h a n g es in the beliefs, progressing step by step so th at th e dam aging
attitudes can b e successively transform ed into ration al ones. Figure
8.10 illustrates th e process.
242 T h e N ew H an dbo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

F i g u r e 8.10 P r o g r e s s iv e im a g e s : m a n - w o m a n fig u r e s d e v is e d b y G e ra ld
F is h e r (1 9 6 8 ).

T he draw ings in this illustration are progressively m od ified from

th e face o f a m an in #1 to th e b o d y o f a w o m a n in #8. Let us a ssu m e
th at w h e n e v e r th e client sees picture #1 h e o r s h e b e c o m e s anxiou s,
b u t the client does n o t get an x io u s u p o n seein g #8. W h e n can the
an xiety b e reduced? At #4, #5, o r later?
For th erap e u tic purposes, clients d o n 't have to shift to # 8 if seeing
# 5 rem oves th eir anxiety. Further sh ifting w ould b e a w aste o f th era­
peutic time. T he p u rp o se o f progressive sh ap in g is to get clients to dis­
rupt th eir patterns ju st e n o u g h to rem o v e th e so u rc e o f th e negative
em otio n . From that p o in t forth, th ro u g h a process o f gestalt sh ap in g
and repetition, clients sh ou ld b e en co u rag ed to w o rk backw ards
tow ard th e original pattern (#1) b y progressively im a g in in g n o a n x i­
ety response, until th e first picture is d iscon n ected from th e em o tio n a l
response.
Perceptual Shifting: Transposing 243
/

T he c h a n g e process reflected in this a n a lo g y accu rately describes

w h a t clients e x p e rie n c e in shiftin g th eir perceptions. W ith th e h elp o f
a therapist, th ey are led grad u ally throu g h a process o f c h a n g in g var­
ious c o m p o n e n ts in th eir gen eral b e lie f structures until they can iso­
late th e so u rc e o f the d iscom fort th a t first b ro u g h t th em into therapy.
O n c e this is achieved, clients are taught to practice the pattern with­
ou t th e p ro b lem c o m p o n e n t. Practice is the m en d in g ingredient.
Clients m ust reh earse seein g th e pattern w ithou t th e problem c o m p o ­
n en t until d o in g so b e c o m e s autom atic.

M ethod

1. H ave clients c o n ce n tra te o n th e key gen eral pattern co n n ected with

their problem , and ask th em to describe it fully. It is ideal if clients
ca n form th e th e m e into a visualization.
2. After e m p lo y in g so m e relaxation to help clients concentrate, have
th e m im ag in e th e th e m e again, b u t to ch a n g e so m e c o m p o n e n t o f
th e pattern. You can c h a n g e a visual co m p o n e n t, an em o tio n a l
c o m p o n e n t, o r so m e o th e r aspect o f th e pattern.
3. C o n tin u e c h an g in g aspects o f th e th e m e until clients report no
e m o tio n a l disturbance.
4. O n c e this occurs, clients c o n ce n tra te on visualizing th e elem en ts in
the ch a n g ed pattern th a t have rem oved the em otion . Th ese should
b e d escrib ed in as m u ch detail as possible.
5. After th e key e le m e n t has b e e n isolated, have y o u r clients picture
th e o th e r th e m e s again, b u t this tim e c h a n g e th e elem en t so th a t no
e m o tio n occurs. If you h a v e correctly isolated the key elem ent, the
clients sh ou ld b e ab le to im ag in e th e scenes without a n y em otio nal
distu rbance.

E x a m p le : The Story o f Chad

C had was a 2 7 -y e a r -o ld m a n w h o sought cou n selin g b ec a u se he
w as deeply depressed. He was an ex cep tion al you ng m a n — bright, cre­
ative, a n d em p a th ic — b u t n ot particularly successful.
C had's overall m istak en th e m e was his vision o f h im self as a per­
son b asically inferior in intelligence, social skills, and em o tio n a l sta­
bility. After initially tea ch in g h im relaxation, w e co n cen tra ted on
c h a n g in g variou s aspects o f this image. W e had him visualize that he
was in ferior in all aspects o f his life b u t work, th en in everything but
w o rk a n d g o in g to parties, then ev eryth in g b u t w ork, parties, and love
relationships. Still, Chad felt depressed.
244 T h e N ew H a n d bo ok of C o g n it iv e T h e r a p y T e c h n iq u e s

We ch a n g ed tactics and had h im im a g in e a n o th e r series o f im ages,

in w hich h e progressively m od ified th e c o n ce p t o f th e o b je c tiv e tru e ­
ness o f his inferiority. In his first picture h e im ag in ed his b e lie f to b e
100% true, th a t in o b je ctiv e reality h e was as in fe rio r as h e im agined,
and h e pictured h im s e lf feeling and acting inferior. In th e n e x t picture
h e im agined that th e th ou g h t was o n ly 75% true. We c o n tin u e d until
th e fifth image, in w h ich h e im ag ined th a t his b e lie f in his ow n infe­
riority was totally untrue.
T h ro u g h o u t the practice, C had visualized h im s e lf c o n tin u in g to act,
feel, and th in k as if h e were inferior, even th o u g h in c o n fir m a b le truth,
h e was not. This exercise led to a very im p o rta n t insight for him. He
discovered that his b e h a v io r and feelings w e re to tally co n tro lled b y
w h at h e th o u g h t rath er th a n b y w h at was c o n firm a b le — th a t sim p ly
th in k in g h im self inferior caused h im to act that way. H e acted a n d felt
exactly th e sa m e at the 2 5 % level o f truth as h e did o n th e 75% level.
The truth or falseness o f his th o u g h t did not affect his b e h a v io r or
em otio n s; on ly his b e lie f m attered. By sep arating c o n fir m a b le truth
an d falseness from th e p ercep tion o f truth a n d falseness, C had was
ab le to g o back to th e original gestalt and se e his m istake. He was
using acting inferior as ev id en ce for b e in g inferior, b u t th e progressive
m od ificatio n process show ed him th at n o m atter h ow h e acted o r felt,
the truth based o n ev id en ce had n o th in g w h a ts o e v e r to d o w ith his
perception.

C om m en t
T he therapist usually doesn't kn ow in a d v a n ce w h a t th e p ro b lem
c o m p o n e n t m ig h t b e in each client's sch em ata. He or sh e m u st th e re ­
fore b e flexible in m od ifyin g th e pattern to find an d t h e n isolate that
c o m p o n e n t.

F u rther In fo r m a tio n
W e con d u cted so m e in form al ex p e rim e n ta tio n w ith pictures like
th e o n e presented in th e analog)'. Using 15 clients, w e fo u n d that th ey
could see th e altern ative im a g e only after th ey had g o n e th ro u g h at
least four m odifications. O u r clinical e x p e rie n c e w ith concep ts, rath er
th an drawings, indicates a c o m p a ra b le response.
Progressive m o d ifica tio n o f th e m e s a n d sc h em a s m a y b e fo u n d in
th e w o rk o f Bugelski (1970), D o b so n and Kendall (1995), K lin ger (1980),
Lazarus (1971, 1977, 1981, 19&>, 1989, 1995, 1997, 1998), Sh eik h (1985a
Perceptual Shifting: Transposing
/

1993b), Sh eik h a n d Shaffer (1979), Sin ger (1974, 1976, 1995), Singer and
P ope (1978), W illiam s (1996a, 1996b).

R a t io n a l E m o t iv e Im a g er y

Principles

A lb ert Ellis a n d o th e r rational em otiv e b e h a v io r therapists have

used a te c h n iq u e called rational em otiv e im agery (RED, w h ich aim s at
shifting clients' overall perceptions. It is included in the transform a­
tion section rath er th a n in th e co u n te rin g section b e c a u s e th e tech ­
n iq u e addresses overall patterns o f th inking rath er th a n specific,
individual cognitions.
In m ost o f th e cogn itiv e tech n iqu es d escribed in this b o o k , th e th er­
apist follows a b a sic p roced u re o f precisely identifying the client's
d a m a g in g beliefs and th en apply ing certain predesigned exercises and
ap p ro ach e s in ord er to facilitate th e chan gin g unrealistic perceptions.
In this role, th e therapist directs th e curative process: He or sh e writes
a prescrip tion and then guides th e client in th e use o f that prescrip­
tion.
W ith the REI tech n iqu e, th e client rath er than the therapist writes
th e prescription. T he therapist helps th e client to identify clearly the
so u rc e o f d iscom fort and to focus deeply u p o n th e core th e m e o f that
d iscom fort (e.g., fear, a feeling o f rejection, a feeling o f inferiority, an
in ten se distrust o f others). O n c e the d o m in a n t co re th em e has b e e n
identified, th e therapist invites the client to focus his o r her creative
en erg ies o n d efining strategies for red ucing the intensity o f th e core
th em e . H ence, in resp on d in g to an in ten se distrust o f others, a client
m ight elect to use w h a t is essentially a cou n terin g te c h n iq u e with
w h ich sh e assures h erself that so m e p eople are m ore trustw orthy than
others. S h e m ig h t em p h asiz e the n ee d to d o a b etter jo b o f determ in ­
ing in a d v a n ce w h o can b e trusted, o r o f not disclosing m atters on
w h ich sh e is m o st v u ln era b le to abuse. Sh e m ig h t decide to adopt
s o m e c o m b in a tio n o f th ese approaches.
Clearly, th e success o f this a p p roach depend s u p o n th ree factors: (1)
th e e x te n t to w hich the client copes effectively w ith a relatively
u nstructured th era p e u tic proced ure; (2) th e ex ten t to w h ich the client
exercises personal creativity in defining cogn itiv e strategies; and, m ost
im p o rta n tly ; (3) th e ex ten t to w h ich the client is ab le to invest h i m - or
h e rs e lf in the th erap e u tic process.
 T he New H an d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

As the ex p e rie n ced read er will recognize, w e h a v e m a d e s o m e slight

m od ificatio ns in Ellis's original c o n ce p tu a liz atio n o f this te c h n iq u e
(see Step #7).

M eth o d
1. It helps to h av e clients relax b e fo re th ey b e g in th e exercise, as it can
im prove th eir con cen tration .
2. Develop a h ierarchy o f 10 situ atio ns in w h ich clients h a v e gotten
upset. Be su re th ese situations are d escribed in en o u g h detail that
the clients can im ag in e th em vividly. S ee if y ou c a n id en tify a n y
c o m m o n d e n o m in a to rs a m o n g th e 10 th at m ig h t h elp y o u to
red uce th em to a few core them es. M a k e sure that clients ag re e that
the final list accu rately reflects the m a jo r sou rces o f th eir d is c o m ­
fort.
3. Ask clients to im ag in e each o f the situations, th e feelin gs th at are
associated w ith th ose situations, and th e co re th e m e s that b est
characterize those feelings. Ask them to keep th ese clearly in mind.
4. Have the clients b eg in with a n y o n e o f those core th em es and focus
o n the associated feeling, using a n y strategies th e y can d ev ise fo r
m od ifying th o se feelings. Have th em keep w o rk in g until th ey start
feeling a c h a n g e in th eir em otions.
5. Tell clients to focus o n w hat th ey told them selv es to m a k e th e feel­
ings shift. If it helps th em to c o n ce n tra te a n d recall m o r e clearly,
have th em write dow n th e advice th ey give them selves. H ave th em
b e c o m e totally aw are o f their beliefs.
6. Clients should practice 15 m in u tes a day until they can consistently
create the alternative em otions. O n ce their first ch o ice co re th em e
has b e e n treated in this way, they shou ld use th e sa m e tech n iqu e
with all o f the rem aining core them es from the list devised in step #2.
7. To help gain con trol o v e r th eir em otio n s, clients can practice feel­
ing different em o tio n s w hile im a g in in g th e original situ ation s that
they recou n ted in step #2. T h ey can practice feeling happy, sad,
angry, confident, relaxed, or- a n y o th e r e m o tio n sim p ly b y altern at­
ing th eir self-talk.

E x a m p le : The Story o f M arg o

Rational em o tiv e b e h a v io r th e ra p y literatu re gives n u m e ro u s
exam p les o l this tech n iqu e. We h a v e included o n ly o n e from o u r c a se­
load. *
Perceptual Shifting: Transposing 247
/

M a rg o was a 2 8 -y e a r -o ld w o m a n w h o c a m e to m e after seeing at

least 6 o t h e r therapists. W ith each o f h er previous co u n selo rs s h e had
tried o n e or tw o sessions, felt n o better, and quit to m ov e o n to
a n o t h e r therapist. This had b e e n g o in g o n for a coup le years.
A fter h e r first few visits, it was clear w h y sh e hadn't m a d e any
progress. Sh e sim p ly was not interested in really w orking at h er ow n
self-im p ro v em en t. S h e was very resistant, answ ering m y p robes with
a sim p le a n d a b ru p t "I don 't know." Sh e did n o n e o f th e assigned read­
ings, n o r did sh e try to learn a n y th in g a b o u t the tech n iq u es or theory
b e h in d th e therapy. Instead, sh e expected, and at times dem anded,
th a t 1 s o m e h o w solve h e r d epression for her. Sh e consisten tly reacted
b ad ly to th e su ggestion that sh e put forth a n y effort.
Highly stru ctu red co g n itiv e tech n iq u es w eren 't affective with
M a r g o b e c a u s e th ey allow ed h er to b e passive in the therapeutic
process. S h e need ed less c o u n s e lo r in v o lv em e n t and m ore client ini­
tiative. It was decid ed th at ra tion al em o tiv e im agery m ight prom p t the
n ecessary participation.
T h e key scen e in M argo's hierarch y was h e r perception that her
p ro b lem s as an adult w ere caused b y her parents. Sh e felt that she
h ad n 't received the n u rtu ra n c e necessary for h er to b e happy, an d that
d epression, h e r b ro k en relationships with m e n , p o o r jo b , and fin a n ­
cial difficulties w e re all h e r parents' fault. Sh e had m isu nd erstood a
c o m m e n t m a d e by a novice an alytic c o u n se lo r years earlier, and as a
result sh e was certain that her parents w ere to b la m e for everything.
S h e h a d n 't seen o r talked to them in five years.
After listening to her tirades against h e r parents, I con clu d ed that
M argo's a n g e r was e x trem e ly overblow n. H er parents had m ad e mis­
takes, as all parents do, b u t it sou n ded like they generally supported
and tried to h e lp their d a u g h te r in th e w ays that they had thou ght
best.
W h e n w e started th e imagery, sh e im agined living with h e r parents
and all o f th e "terrible" things th e y had don e. T he em o tio n sh e recog­
nized was in ten se rage. W h e n sh e was told to shift it to a lesser e m o ­
tion, su c h as a n g e r or disap p oin tm en t, sh e said sh e couldn't, but it
b e c a m e clea r from her n o n v e rb a l b e h a v io r that sh e wouldn't. She
asked to try s o m e th in g besides this techn iqu e, b u t 1 refused and per­
sisted in using it. Sh e b e c a m e angry with m e fo r not granting her
request, b u t I c o n tin u e d th e s a m e tech n iqu e. T h e session end ed in a
stalem ate.
M a rg o can celed th e n ex t three ap p o in tm en ts. I heard later th at she
w e n t to tw o o th e r therapists for sessions, look in g to th e m to solve her
248 T h e N ew H an dbook of C o g n it iv e T h e r a p y T e c h n iq u e s

depression. A m o n th later s h e 'c a m e b a ck t o see me, still a n g ry b u t

"ready to give m e o n e last try." S h e ex p e cted that s h e had sufficiently
pu nished m e and that I would drop the rational e m o tiv e imagery, b u t
I did not.
It shou ld b e noted, parenthetically, th at this p ersisten ce is u n usual
in cognitive restructuring. G en erally i f o n e te c h n iq u e d o e sn 't w ork, I
freely sw itch to another. But n o th in g w orked w ith this client. H er fail­
ures w ith th e previous six therapists w e re n o t th e fault o f th e th e r a ­
pists or their techn iqu es. I felt it had b e c o m e n ecessary to do
s o m e th in g radically different, and that sticking w ith o n e te c h n iq u e
rath er th a n allow ing M a rg o to escap e th e p ro b le m m ig h t b e w h at was
needed. If I were to attem pt this with 10 different clients, I w ould
p rob ab ly fail 9 o u t o f 10.
After talking to her frankly a b o u t w h a t I th ou g h t th e p ro b lem was,
w e c o n tin u e d th e ration al em o tiv e imager}'. S h e did not fully c o o p e r ­
ate, b u t this tim e sh e did m a k e so m e changes. S h e red uced h e r rage
slightly b u t said that the o n ly w ay sh e could acco m p lish this was to
say to h erself that sh e was so m ew h a t respon sible. W h e n s h e said that
to herself, sh e b eg an to feel scared and q u ite guilty. I th e n sw itched
the im agery w ork to th e n ew p ercep tio n o f s e lf-b la m e and fear. Using
rational em o tiv e im ag ery sh e was ab le to red uce th ese feelings s o m e ­
what. We th en alternated th e im age w o rk b e tw e e n a n g e r tow ard her
parents and fear and guilt a b o u t herself. Gradually, o v e r a period o f
m a n y sessions, M argo was a b le to red uce h e r guilt and a n g e r until h er
depression lifted.

C om m en t
T h e flexibility o f this te c h n iq u e is its greatest v irtu e and its greatest
flaw. S o m e clients n eed m ore specific instru ction on how to c h a n g e
their em otions. O th ers prefer taking m o r e resp on sib ility for th e ir ow n
perceptual shifting.

F u rther In fo r m a tio n
The tech n iq u e is d escribed in several p u b lica tio n s: M a u ltsb y and
Ellis (1974), M au ltsb y (1971, 1976, 1984, 1990), an d W ild e (1998).
Perceptual Shifting: Transposing 249
/

Im a g e T ec h n iq u es
Principles

Im ages are used in tran sform ation s and o th e r aspects o f cognitive

restru ctu ring; a b o u t a third o f th e tech n iq u es listed in this b o o k use
so m e form o f imagery. W h ile c o u n te rin g attem pts m odify clients' lan­
gu age far m o re th a n th eir images, tran sform ation s are prim arily based
o n im ages an d visualization. Im ages b etter show w h a t clients need to
c h a n g e in ord er to feel b etter b e c a u s e they stress the overall p a ttern -
shifts, w h ile purer linguistic tech n iq u es aim at ch an gin g m ore specific
thoughts.
Still, even pure linguistic te c h n iq u e s can b e adapted into image
visu alization procedures. For m a n y clients, th e b est approach is to
in terw eav e linguistic and im aging techn iqu es, as the co m b in a tio n
p ro d u ces m ore pow erful ch an g es th an o n e approach alone. However,
if a client is especially adept at visualization or seem s especially
resp onsive to im age m od ification, th e therapist may wish to e m p h a ­
size th e im age work.

M eth od
1. In ord er to turn langu age tech n iq u es into tran sform ation tech ­
niques, c o m p le te the first th ree steps o f CRT: Find the client's core
m e ta p h y sica l beliefs (Guidano, 1991; G u id ano & Liotto, 1983),
o b je ctiv e ly an alyze th e ir truths or falsehoods, and develop a series
o f c o u n te rs o r rational rep lacem en t beliefs (Me M ullin & Giles,
1981).
A lthou gh th ese th re e steps can use visualization successfully, we
hav e found that la n g u a g e gen erally is a m ore flexible to o l than
v isu aliza tio n in th e initial stages o f CRT, largely b ec a u se o f prob ­
lem s clients e n c o u n te r in visualizing their beliefs. It is difficult, for
exam p le, to im a g in e visual im ages to a c co m p a n y a b e lie f such as, "1
feel I h av e n o p u rp o se in life." W e r e c o m m e n d the use o f linguistic
te c h n iq u e s in th e early stages for th e sake o f simplicity and effi­
ciency.
2. D e te rm in e th e im ag in ing capacity o f clients b y using o n e o f the
scales d ev elo p ed b y Lazarus (1977, 1981, 1982, 1989, 1995, 1998).
T h ese scales h elp to d e te rm in e the client's overall visualization abil­
ity an d to p in p o in t areas in need o f im p rov em en t. T hey ex a m in e
 T h e N ew H a n d bo o k of C o g n it iv e . T h erapy T e c h n iq u e s

th e client's ability to create im ages o f se lf vs. oth ers; past, present,

and future; pleasant and u n p leasan t; and a ran ge o f o th e r areas.
3. If clients score low o n their visualization capacity, y ou m a y w ish to
em ploy th e im a g e -b u ild in g te c h n iq u e s d escribed b y Lazarus (1982).
4. Select specific im ages to help y o u r clients shift from irrational
beliefs to rational ones. S in ce im ages d o n o t in volv e language,
clients can o ften shift th eir percep tion s m o re rapidly a n d c o m ­
pletely b y using visual im ages rath er th a n sem antics. You can use
m a n y different types o f im ages to crea te th ese perceptual shifts. Fol­
lowing is a list o f so m e o f the m a jo r types.

• Coping images, in w h ich clients im ag in e them selv es successfully

handling difficult situations, are used to correct passive, avoid an t
thinking. ("Picture asking y o u r b o ss for a raise.")
• R elaxing images, in clu d in g n a tu re scen e s an d sen su a l visualiza­
tions, are used to c o u n te r fear-p rod u cin g , a n x io u s thoughts.
These are frequ en tly used as part o f cogn itiv e desensitization.
• M astery images, in w hich clients im a g in e th em selv es co m p letin g
tasks perfectly, can b e paired against irrational th o u g h ts o f fail­
ure and helplessness. ("Im agine havin g a successful, ha p p y m a r­
riage.")
• Sm all-detail cop in g im ages, w hich focus o n specifics, h elp clients
w h o feel o v erw h elm ed b y c o m p le x p rob lem s. W ith this m ethod ,
clients b reak m a jo r p rob lem s into a series o f m in o r o n e s and
im a g in e th em selv es s u rm o u n tin g each o f th ese sm a ller difficul­
ties. For instance, a clien t m ig h t b reak d o w n th e p ro b lem o f b u y ­
ing a c a r into 2 0 small tasks and im ag in e successfully co m p le tin g
each co n secu tiv e task, b e g in n in g with b u y in g Consumer Reports
New Car Guide a n d en d in g w ith th e successful p u rch a se o f th e ideal
vehicle.
• M o d elin g im ages m a y b e used i f a client has tr o u b le en v isio n in g
the c o m p o n e n t steps in resolving a p r o b le m o r m a ste rin g a skill.
In this tech n iq u e, the client pictures im itatin g a m o d e l w h o
excels in a given task. For in sta n ce, the client m ig h t a n a ly z e and
th e n visualize th e fo reh an d stroke o f Pete S am p ras o r th e d e b a t­
ing skill o f W illiam F. Buckley.
• N oxious im ages are u sed in aversive, escape, an d a v o id an t c o n ­
d itioning to c o u n te r n eg ativ e beh aviors. ("Picture y o u r sm o k in g
cau sin g y o u r kids to gel em physema.")
• Idealized im ages are used w h e n clients ca n 't th in k o f th eir final
Perceptual Shifting: Transposing 251
/

goal. ("Ten years from now, w h ere do you w ant to b e living, and
w ith w h o m ? W h a t d o you w ant to b e doing?")
• Rew arding images rein force realistic thinking. ("What goo d
things could h a p p e n to you if you finish the project?")
• Leveling im ages red uce th e negative effects o f aversive, fearful
visualizations. ("Picture you r b o ss in a duck costum e, quacking.")
• R econ cep tu alizin g images ch a n g es th e interpretation o f events.
("Im agin e th at you r wife w asn't angry at you, b u t had had a bad
day at work.")
• Negative vs. positive images— visualizing a negative situation
against a positive back grou n d , as in h ig h e r-o rd e r conditioning,
c an c h a n g e th e em o tio n a l v ale n ce o f the situation. ("Im agine
b e in g criticized b y an antagonist, w hile sitting in a tropical
lagoo n o n a w arm su m m e r day")
• C orrective im ages u n d o m istakes the clients have m ade in the
past. ("Picture h ow you w ould do it if you had it to d o all over
again")
• G eneralized correctiv e images have th e client correct all past
in cid en ce o f a specific type. For exam ple, a passive client might
im ag in e h a v in g b e e n assertive ever)' m a jo r time h e had b ack ed
aw ay from a problem .
• Future persp ective im ages h av e clients look back to th e present
situ ation from s o m e future tim e, thereb y clarifying key values.
("Im agine y ou are 85 lo o k in g back at y o u r life. W h a t do y ou c o n ­
sider im p o rta n t and u n im p o rta n t now?")
• Blow u p im ages te a c h clients to co p e with the w orst possible c o n ­
se q u e n c e s o f an event. ("W hat is the worst thing that could pos­
sibly h a p p e n as a result o f losing you r jo b ? W h at w ould you do
a b o u t it?")
• V isualization o f low -p ro b ab ility im ages requires that clients pic­
ture all th e terrible events that could h ap p en to them , so that
th ey learn to give up trying to con trol everything. Paradoxical
te c h n iq u e s o ften e m p lo y th ese images. ("What terrible things
could h a p p en to y ou w hile reading th e Su nd ay fu nnies? W hile
takin g a b ath ? W h ile lying in y o u r bed?")
• Assertive resp o n se im ages m ay b e contrasted with images of pas­
sive, aggressive, and passive-aggressive responses, so that the
c lien t can see the co n se q u e n ce s o f each response. ("Im agine ask­
ing fo r y o u r m o n e y b a ck passively, aggressively, and assertively.")
• U ltim ate c o n se q u e n c e s im ages have clients visualize a tro u b le -
 T h e N ew Han d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

so m e situation a week, m o n th , or y e a r after th e e v e n t to deter­

m in e th e lasting c o n seq u e n ce s. ("If y ou kill yourself, h ow sad do
you im ag in e y o u r girlfriend will b e 8 years from now?")
E m p athy im ages teach clients to p erceiv e th e w orld from
an oth er's internal fram e o f reference. ("How d o e s th e p e rso n you
hurt feel a b o u t you?")
C athartic images allow th e client to im ag in e ex p ressin g p rev i­
ou sly u nexpressed em o tio n s like anger, love, jealousy, o r sadness.
("Im agine yelling b a ck at y o u r boyfriend")
Zero reaction im ages h av e clients visualize receiv in g o n ly neu tral
c o n se q u e n ce s in p h o b ic situations. T hese im ages are o ften used
in extin ction procedures. ("Im agine g e ttin g up in front o f the
w h ole co n g reg a tio n and th en w alking out. Picture n o b o d y n o tic­
ing o r caring")
Fanciful im ages solv e p rob lem s in im ag in atio n th at c a n n o t b e
solved in reality. ("Picture y o u r dead g r a n d m o th e r b e fo re you
now. W h a t advise w ould sh e give y o u ? H ow d o e s s h e feel a b o u t
w hat you h a v e done?")
Preventive im ages are used to prep are clients to c o p e w ith p r o b ­
lem s th ey m a y e n c o u n te r in th e future, su ch as death, rejection,
physical illness, poverty, etc.
Negative reinforcing im ages in volv e th e clients' im a g in in g a fear­
ful situation that rem oves th em from a n ev en m o r e fearful situ­
ation. ( Im ag ine that hold ing a sn a k e keeps you fro m b e in g
criticized b y y o u r peers.")
Secu rity images give clients a feeling o f safety in a th re a te n in g
situ ation ("W hen you are o n the plane, im ag in e y o u r m o th e r is
hold ing you in y o u r warm , pink blanket.")
Satiated im ages, used in covert flo o d in g procedures, rep eat the
s a m e visualization o v e r and o v er again until th e client gets tired
o f im agining it. ("Imagine, 50 tim es a d ay for th e n ex t tw o weeks,
that y o u r wife m ak es love to ev ery m a n you see.")
A lternative im ages are used w h en clients m u st d e cid e b etw e en
different courses o f action'. ("Visualize w h a t y o u r life w o u ld b e
like living in New York City for th e n ex t y e a r versus w h a t it
w ould b e like living in Key West, Florida.")
Negative c o n se q u e n ce s im ages sh o w the aversive results o f
so m eth in g th e client m ay se e as positive. ("Im agine th at after you
b e c o m e fam ous you are trapped in y o u r hou se, u n a b le to go
a n y w h ere b e c a u s e the paparazzi are stalk in g you.")
Perceptual Shifting: Transposing 253
/

• R e s istin g -tem p ta tio n images turn app ealing o b je cts into aversive
o b je cts ("Im agine y o u r cigarette is dried buffalo chips")
• T im e -tr ip p in g im ages allow th e clien t to d e ta ch from a distress­
ing in cid e n t b y im a g in in g g o in g forw ard in tim e (6 m o nths) and
t h e n lo o k in g b a c k o n th e in cid e n t (Lazarus, 1998). ("Im agine
h o w y o u will feel in 6 m o n th s a b o u t y o u r b o y frie n d d u m p in g
you.")

5. H ave clients practice visualization until selected im ages b e c o m e

vivid.
6. After clien ts finish practicing th eir im ages, rein tro d u ce th e la n ­
g u a g e c o m p o n e n t b y ask ing th e m to su m m a riz e ch an g es in their
b e lie f system. ("Now th at you h av e sh ifted y o u r e m o tio n s b y using
th ese im ages, w h at are y o u r co n clu sio n s? W h a t irrational th ou ghts
w e re y ou th in k in g b efo re ? W h a t rational beliefs d o you have
now?")

E x a m p le
As im plied ab ov e, specific images are paired with specific irrational
beliefs in ord er to b rin g a b o u t cogn itive changes. Below are so m e o f
th e visualization s w e h a v e u sed to correct various client irrationalities.

Core belief: People m u st always love m e o r I will b e miserable.

Corrective im ages: Progressive cop in g images. Provide clients with coping
im ages th a t sh o w th em : (a) b e in g loved b y everyone, (b) b e in g loved
b y e v e ry o n e in th eir e n v ir o n m e n t except for o n e person, (c) b ein g
loved b y m ost people, (d) b e in g loved b y h a lf th e p eople they know,
(e) b e in g loved b y o n ly a few p e o p le in their en v iro n m en t, (f) b ein g
loved b y o n ly o n e person. D escribe th ese im ages in such a way that
clients successfully c o p e with a decreasing n u m b e r o f p eople w h o love
them .

Core belief: M a k in g m istakes is terrible.

Corrective im ages: N oxious im ages m ay b e used. Clients pair the aversive
im ages w ith trying to b e perfect all the time. ("Im agine the suicidal
b o r e d o m p erfection w ould bring")

Core belief: It’s terrible w h en things g o wrong.

Corrective im ages: Leveling and ze ro -re a c tio n images. Have clients pic­
tu re n o th in g at all h a p p e n in g w h en so m e th in g goes wrong.
254 T h e N ew H an d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

Core belief: M y e m o tio n s can 't b e 'c o n tr o lle d . v

Corrective im ages: Rew arding images. Teach th e client to im a g in e all the
positive c o n se q u e n ce s o f h a v in g th eir e m o tio n s .free and sp o n ta n e o u s.

Core belief: Self-d iscip lin e is to o hard to achieve.

Corrective images: M astery images. Clients picture ex cellen t se lf-d isci-
p lin e in a variety o f situations.

Core belief: I m u st alw ays d ep en d on others.

Corrective images: Idealized images. Clients visualize scen e s o f freedom ,
in d ep en d en ce, an d b e in g untethered.

Core belief: M y b ad ch ild h o o d m u st m a k e m y adult life m iserable.

Corrective images: M o d elin g images. Clients im ag in e a w h o le series o f
p e o p le w h o h a v e b e e n h ap p y and successful despite having h ad a
horrib le childhood.

Core belief: I b eliev e th ere is a right, correct, perfect so lu tio n for m y

prob lem s an d all I h av e to d o is find it.
Collective im ages: Sm all-d etail cop in g images. Have clients im a g in e the
necessary b u t sm all steps th ey m u st tak e to solv e each specific p ro b ­
lem.

Core belief: I am an ex cep tion al person (a prince in disguise o r Clark

Kent look in g for a p h o n e booth). I requ ire special privileges and
favors, therefore, I sh ou ld n 't have to live w ith in th e limits a n d restric­
tions o f o rd in ary mortals.
Corrective im ages: E m p ath y images. "If you w ere s o m e o n e else, w'ould
you w an t to b e friends with you ? W ould y ou like b e in g a ro u n d you?"

C om m en t
S o m e cognitive therapies prim arily e m p h a siz e linguistic tech n iqu es,
w hile others em p h asiz e images-. In co g n itiv e restru ctu ring w e have
found the c o m b in a tio n far m o re effective than e ith e r o n e alone.

Further In fo r m a tio n
The literatu re on im agery is extensive. T h e read er sh ou ld refer to
the m a jo r w orks o f Kosslyn (1980), Kosslyn and P o m e ra n tz (1977),
Perceptual Shifting: Transposing 255
/

Lazarus (1977, 1982, 1989, 1995, 1998), Lazarus and Lazarus (1997),
R ich ard son (1969), S h e ik h (1983a, 1983b), Singer (1974, 1976, 1995), and
Sin g er an d P ope (1978). Im agery is also a m a jo r c o m p o n e n t o f two
o th e r therapies that are often used a lo n g w ith cogn itive restructuring:
sc h e m a -fo c u s e d th erap y (M cG inn & Young, 1996) a n d fo c u sin g -o r i-
en te d p sy ch oth erapy (Gendlin, 1996a, 1996b).
 V V

Perceptual Shifting:
Bridging

B r id g in g h e l p s c l ie n t s m o v e from old, d a m a g in g beliefs to new, m o re

useful attitudes. It does this th rou g h th e use o f a n c h o rs th at b rid g e old
attitudes with new. A n ch ors can b e th ou ghts, images, words, sy m b ols,
or a n y o th e r typ e o f m ental asso ciation that carries th e clien t from o n e
th ou g h t to th e other. Usually these a n c h o rs are alread y in th e client's
repertoire; it is the therapist's jo b to help th e client a sso cia te th e m
with new beliefs and to m a k e th e c o n n e c tio n s stro n g and persistent.
T he first three tech n iq u es in this ch ap ter use a n c h o rs alread y in use
b y the client: general anchors, valu e anchors, and w o rd a n d sy m b o lic
anchors. T he last te c h n iq u e , h i g h e r -o r d e r c o n d itio n in g , creates
a n ch o rs that are n ot already in th e client's repertoire.
A lthough bridging m a y seem to b e an ad v an ced co g n itiv e te c h ­
n iq u e used o n ly b y m en tal h ealth professionals, it is actu ally qu ite
c o m m o n and has b e e n used for centuries b y th e g e n eral public. S o m e
h av e even m a d e it into an art. Two ex am p le s clarify this point.

E x a m p le 1
W h e n I was a new psychologist w o rk in g at m y first jo b after grad­
uation, I was driving d ow n the m a in street o f a sm all tow n in w estern
Pennsylvania. A h ead o f m e I noticed a y o u n g b o y riding his b ike
across a b u sy street. He didn't n otice a c a r in front o f him , a n d ran into
it head first. He collapsed u n co n scio u s o n the street, his b ik e a m a n -
g w m ess, w hile cars pulled o v e r and p e o p le g o t o u t to see i f they
could help. I was a m o n g them .
T he police and an a m b u la n c e w ere called. T he b o y had o n ly a mild
Perceptual Shifting: Bridging^ 257

co n cu ssio n and, ex c e p t for h aving a h e a d a ch e for a few days, h e was

fine. At th e tim e, however, he didn't look fine. His m o th e r had b een
co n tacted im m ediately, and sh e c a m e ru n n in g as fast as sh e could
tow ards th e accident. W h e n s h e saw her son lying u n co n scio u s on the
street, s h e started to scream . Sh e scream ed as loudly as sh e could and
flailed h e r a rm s b a ck a n d forth as sh e kept ru n n in g toward him. Her
screa m in g was as loud and intense as 1 had ev er heard; her face
tu rn e d bright red, and s h e started to p ou n d the street w ith h e r fist. As
th e b o y regained c o n scio u sn ess th e o n lo o k ers started to worry more
a b o u t th e m o th e r th an th e son.
Everyb od y tried to calm her down. We told her that the am b u lance
had b e e n called and that it looked as if her son wasn't seriously hurt.
W e suggested th at she might find it useful to relax h er breathing. She
looked as if s h e hadn't heard a word we said and continued screaming.
At th a t p oin t an au to m e ch a n ic from a n earb y gas station cam e
ru n n in g up. He looked at the boy, turned to the mother, and said in a
quiet, soft voice, "Your screaming is hurling your son. He needs your help NOW,
not your yelling. Go and comfort him!"
S h e lo o k ed at h e r son, th en at the m echanic, and th en b a ck at her
son. Suddenly, instantaneously, sh e stopped. Sh e ceased yelling in
m id -screa m , w ith no residual w h im p ers o r sobs, as if sh e had cut her
e m o tio n s o ff w ith a knife. Sh e calm ly b e n t dow n and stroked h er son's
forehead, w'hispering to him until the a m b u la n ce arrived.
W h ile th e b o y was not seriously injured, w h a t is striking is the
p ow er o f the m e ch a n ic's statem ent. He had said exactly th e right thing,
in ex a ctly th e right way, at exactly th e right time. This is a classic
e x a m p le o f bridging. T he m other's old thought, "It's terrible, horrible,
a n d cata stro p h ic that m y son is injured and I can't stand it" was
b rid ged to th e new attitude, "M y s o n needs m y help." T h e a n c h o r that
c o n n e c te d th e tw o was, "Your scream in g is hu rting you r son." Her
desire to help h er son had already b e e n deeply ingrained in her reper­
toire; all th e m e ch a n ic had to d o was to sh ow the m o th e r that her
a ctio n s w e re violatin g h e r deeply ingrained belief.
S o m e o f th e best bridge builders in o u r society have n o training or
degrees. A cadem ic ed ucation can provide helpful theoretical inform a­
tion, b u t e x p e rie n ce with p eople is th e b est tea ch er for bridge building.

E x a m p le 2
In an oth er incident, som e w e ll-k n o w n professor types were
a p p e a rin g o n a talk sh o w to discuss their differing theories o n the
258 T h e N ew H an d bo o k q f _ C o g n it iv e T h e r a p y T e c h n iq u e s

causes o f poverty. T hey w ere c o lleg e professors, ec o n o m ists, political

scientists, agronom ists, sociologist, eng ineers an d th e like; all had a
Ph.D. and w ere p re e m in e n t in th e ir fields. T h e e n g in e e r said that
poverty is caused b y a lack o f indu strialization w h ile th e political sci­
entist suggested th a t political conflicts were th e culprit. T h e so c io lo ­
gists discussed class stratification, th e e c o n o m ist talked a b o u t supply
and d em an d . T hey all argued a b o u t th e p ro b lem in great detail. T hey
w ere well inform ed, lucid, a n d certain ly seem ed to k n o w w h a t th ey
were talking a b o u t. The intricacies o f th e ir a rg u m e n ts w ere impressive,
but th e studio au d ien ce seem ed to have difficulty d ecid in g w h ich o f
their c o m p le x theories was correct.
That ev en in g a public television station presen ted a d o c u m e n ta r y
a b o u t th e late M o th e r Theresa. It m ostly sh ow ed h e r h elp ing th e p o o r
and sick in pov erty-stricken areas o f India, Peru, Leban on, and o th e r
countries. In a b rief scen e sh e was sh o w n c lim b in g steps w ith h e r sis­
ters into a build ing in Calcutta. A n ew sp a p er rep orter was sh o u tin g
q u estio n s at h e r b u t sh e didn't respond. Finally the rep o rte r asked,
"W h y are th ere so m a n y p o o r p eople in the w orld?" S h e kept o n w alk­
ing, b u t at th e top o f th e stairs s h e turned arou n d , look ed him in the
eye and said, “Because people don'I share.'' Sh e tu rn e d arou n d a n d c o n tin ­
ued into th e building.
The d o c u m e n ta ry didn't dwell o n this m o m e n t o r c o n sid e r the
c o m m e n t a rem ark a b le thing; it qu ickly m o v ed o n to o th e r ev en ts in
M o th e r Theresa's life. N onetheless, h e r sta tem e n t w as sh ocking . It
seem ed a facile th in g to say a b o u t s u c h a c o m p le x p rob lem , b u t th e
m o re I th o u g h t a b o u t it th e m o re I realized th at s h e was ex a ctly right.
Her sh ort se n te n c e had cut th ro u g h all the eru d ite c o m m e n ts th at the
professors had m a d e and captured th e co re o f th e matter. It was a
pow erful th in g to say, and an ideal bridge. It ch a n g ed the v ie w o f
poverty im m ed iately and completely.
O ver the years p e o p le from diverse b ack g ro u n d s h av e sh o w n the
ability to b e ex cellen t bridge builders. W h e t h e r sta tesm en o r used car
salesm en, poets or A rm y sergeants, au to m e ch a n ics o r tiny old ladies
dedicated to h elp in g the poor, th ey all sh a re the ab ility to find t h e key
to the way p e o p le p erceive so m eth in g , and to m a k e a sta te m e n t th a t
bridges to a n o th e r b e lie f an d produces a dram atic, c o n c e p tu a l shift.

B r id g e P e r c e p t io n s

Principles

Clients lea rn new in fo rm a tio n m o re readily if s o m e c o m p o n e n t o f

th a t n ew in form ation is already stored in th eir m em ories. T h a t c o m ­
Perceptual Shifting: Bridging 259
/

m o n ele m e n t b e tw e e n th e old know led ge and the new constitutes a

b rid g e across w h ich clients can m o v e m ore easily from m istaken
beliefs to m o re rational, fu nctional thoughts. This type o f transition is
illustrated in th e follow ing exam ple.

E x a m p le 1
Old belief: People are n o g oo d . T hey are m e an an d spiteful.
New Belief: People are people. T h ey act the way n atu re planned. S o m e ­
tim es w e like w'hat th ey do, so m etim es w e don't.

The therapist m ight attem p t to m ov e th e client from the old belief

to th e new b e lie f b y em p lo y in g c o u n te rin g techniques, b u t there is a
stro n g p ro b ab ility th a t it will neither b e as efficient n o r as lo n g -la st-
ing as th e results that could b e derived from th e bridging technique.
U p o n careful analysis o f the old belief, th e reader shou ld n o te that
th ere are tw o c o m p o n e n ts th a t serve as a bridge to th e new' belief: the
su b ject "peop le" and th e assessm en t that "they are m ean and spiteful."
T h e new b e lie f is also co n ce rn e d with "people," and it too acknow l­
edges th a t h u m a n b e h a v io r can b e disappointing, but it interprets that
reality as a fact o f "nature."
For exam p le, o n e o f m y clients hated adults for b ein g m ean and
spiteful b u t revealed du ring ou r sessions th at sh e loved babies. Why, I
asked, didn't sh e dislike babies, w h o m so m e p eople m ight consider
"m e a n and spiteful" for throw ing tantru m s, wetting their pants, or
spitting up food ? "That's silly," argued th e client. "They're just doing
th o s e things naturally."
W e p o in ted o u t that p eople w h o yell at us b ec a u se they h a v e a cold
o r w h o w ithd raw w h en they are scared are actin g o u t o f m uch the
s a m e m o tiv a tio n as b a b ies— naturally. If sh e could accept and even
like b ab ies, p e rh ap s sh e could accept su ch adults as well. "Babies" is
th e a n c h o r th at carries the e m o tio n from o n e attitude to another.
The client practiced c h an g in g h er im ag e o f adults. Every tim e p eo­
ple did s o m e th in g sh e didn't like, s h e co n cen tra ted on picturing th em
n o t as adults, but as big b abies dressed in adult clothes, speaking in
adult w ords b u t w ith the u n d erly in g m otivation o f a baby. After pic­
turing 43 situations with this image, s h e was ab le to adopt a new and
m o r e ra tio n a l attitu d e toward adult m isbehavior.

M eth od
1. Use clients' m a ster list o f beliefs.
2. M a k e a c o m p a n io n list o f possible rep lacem en t beliefs, m a k in g cer-
260 T h e N ew H a n d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

tain th a t y o u r clients ag re e th a t th ese w ould b e m o r e useful per­

cep tio n s if th eir validity could b e dem onstrated .
3. During counselin g , search for an attitu d e alread y accep ted by
clients that could bridge the old p erception to th e new. In so m e
cases y ou will n eed a series o f th em es an d it m a y ta k e y o u an d y o u r
clients so m e tim e to find them . Pick bridges that h av e th e m o st per­
sonal m e an in g for clients so that th ey can b e tied m ost directly with
their c o n ce p t o f self.
4. O n c e th e bridges have b e e n identified, h av e clients practice shifting
their beliefs from th e old to the new. T h e practice shou ld c o n tin u e
until th e new attitude replaces th e old. I f e n o u g h real situ atio n s do
n ot exist, en co u ra g e y o u r clients to im ag in e as m a n y su ch situ a­
tions as possible.

E x a m p le 2
Old belief: T he client is afraid o f riding a ski chairlift. "If I get a n x io u s o n
the ch air I w'on't b e ab le to escap e for 10 m in u tes, a n d I c o u ld lose
c o n tro l and em b arra ss myself."
New belief: A chairlift is an o p p o rtu n ity to relax, lo o k at th e b eau tiful
w inter scenery, an ticip ate th e d o w n h ill run, and talk w ith a friend.
Bridge belief: T h e follow ing e x c h a n g e illustrates h o w a bridge can b e
established.

THERAPIST: Skiing is a risky sport, w o u ld n 't y ou agree?

CLIENT: Sure, b u t I e n jo y it.
THERAPIST: Then you e n jo y takin g risks?
CLIENT: It's the o n ly w ay to really e n jo y life to th e fullest.
THERAPIST: Aren't th e re riskier aspects to skiing th a n in riding the
chairlifts?
CLIENT: Well . . . yes. I guess so.
THERAPIST: Why, then, are you u n n erv e d b y th e lesser risk?
CLIENT: Gee. I don 't know. I guess, n ow that I th in k a b o u t it, it
doesn't m a k e a lot o f sense, does it?

T h e client and I w rote the follow ing b rid g e b e lie f in this e x a m p le

into a m ore general p h ilosop h y fo r th e client to read each week.

You can lo o k at all th e en jo y a b le, pleasurable, o r b eau tifu l

things in life negatively. W h ile you relax o n an o c e a n b e a c h a
tidal w ave could e n g u lf you o r a great w h ite sh a rk c o u ld g o b b le
you up. You could b e b itten b y a b la ck m a m b a sn a k e w h ile lying
Perceptual Shifting: Bridging.
/

o n soft grass n ex t to a g en tle co u n try stream . W h ile sailing u nder

a silver m o o n o n a C arib b e an lagoon, you could hit a coral reef
and drown. A sparrow in an English m e ad o w could suddenly
attack you a la H itchcock. You could b rea k y o u r eard rum s while
listen in g to M ozart's Ju p iter sym ph on y, o r y o u r stereo system
c o u ld ele ctro c u te you. W h ile m ak in g love you could have a heart
attack o r catch a disease. Even if you w atch o n e o f you r favorite
plays b y G eorge Bernard Shaw, the th ea ter could catch on fire.
You could also w o r n ' a b o u t playing with you ng children b ecau se
s o m e adult could accu se you o f m olesting them , o r you could
c h o k e to d ea th eating a tender, ju icy dru m stick from your
m o th e r's T h an k sg iv in g turkey.
You c o u ld try to protect y o u rse lf by avoiding all th e e n jo y a b le
a n d pleasu rab le things o f life. You could retreat to you r room
a n d w o rry a b o u t b e in g trapped in an e a rth q u ak e or the room
catch in g o n fire. But o n c e you throw away th e bright and b e a u ­
tiful, w h a t w o rth w h ile asp ect o f life do you have left to protect?

E x a m p le 3
Old belief: From a tee n a g e b o y : "My parents prefer m y old er brother.
T h ey g iv e h im everythin g, and I get w hat is left over."
New belief: "Our parents love us b oth , b u t they treat us differently
b e c a u s e w e are different people. T hey celeb rate m y individuality and
w o u ld n 't w a n t m e to b e a c lo n e o f m y brother. They give m e what
th e y th in k I need, and m y b ro th e r w h at h e needs."
Bridge belief: The therapist gleaned th e following ex a m p le from the
client's person al history. "R e m e m b e r th e two kittens you r parents asked
you to take care o f w h en you were you ng ? O n e was w arm and fuzzy
an d alw ays w an ted to b e petted; h e loved to cuddle next to you while
y ou slept. T he o th e r was frisky and adventuresom e; h e was always
chasing mice, clim b ing trees, and getting into y o u r potted plants. If the
kittens could speak, o n e could h av e accused you o f giving m ore free­
d o m to his brother, the o th e r o f not giving him en o u g h love. But you
loved th em b o th and didn't prefer o n e over the other. You gave b oth
w hat they needed. M a y b e y o u r parents are treating y ou th e sam e way."

C om m en t
If you can find exactly th e right bridge, y o u r client's perceptions
will c h a n g e dram atically, and y o u r client w o n 't h a v e to invest a great
262 T he N ew H an dbo o k o f _ C o g n it iv e T h e r a p y T e c h n iq u e s

deal o f tim e and effort in practicing th e new perception. But you m ust
search patiently with y o u r clien t in o rd e r to find th e b rid g e th a t has
th e strongest and m ost person al m eaning.

F u rther In fo r m a tio n
Finding th e k e y bridge p ercep tion m ay b e the c o r e e le m e n t u n d e r­
lying rapid religious or o th e r types o f c o n v e rsio n (Sargant, 1996).
Sy m o n s a n d Jo h n s o n (1997) reviewed a variety o f studies a n d c o n ­
firm ed th e im p o rta n ce o f m a k in g bridges p e rso n a lly relevant. T hey
determ ined that su b jects b est r e m e m b e re d th o se c o n ce p ts th a t had
the m ost self-references.
O th er therapists use m eta p h o rs as bridges (see G ordon, 1978; M a r­
tin, C um m ings, & H allberg 1992; an d Neukrug, 1998; Shorr, 1972, 1974).

H ie r a r c h y o f Va lu es B r id g e s

Principles

O n e o f the m ost effective types o f bridges, an d o n e o f th e therapist's

m ost im p o rta n t tools, uses the client's v a lu e system as a n anchor. O u r
e x p e rie n ce show s that an ap p eal to p erson al valu es is a high ly effec­
tive bridging techniqu e. Values offer th e a d v a n ta g e o f b e in g p ro p rio ­
ceptive and deeply rooted w ithin clients' co n ce p ts o f reality. Clients
frequ en tly will n o t accept a rational ju d g m e n t that their attitudes or
b eh a v io rs are incorrect, b u t th ey will rarely refute a p rov en discrep ­
a n cy b etw e en th eir attitudes o r b e h a v io rs and their actu al values.
T h rou gh careful m a n a g e m e n t o f th e th era p e u tic process, th e c o u n ­
selor can help clients get in to u ch with their person al h ierarch y o f v a l­
ues. Old, m istaken beliefs are also associated w ith th at hierarchy, b u t
if the therapist can d e m o n stra te that new, preferred beliefs e n jo y a
higher v alu e o n that hierarchy, h e or s h e can facilitate clients’ m o v e ­
m en t toward a m ore effective attitude.

M eth o d
1. Discover th e client's person al h iera rch y o f values. This can b e d o n e
b y using a stan dard ized valu e test, o r a b e tte r m e th o d is to find the
values th ro u g h selective qu estion in g . D istinguish b etw e en q u es­
tions th a t m erely elicit valu e ju d g m e n ts ("How d o you feel a b o u t
marriage?'') and q u estio n s th at force clients to rank their v a lu es in
Perceptual Shifting: Bridging 263
/

an h ierarchical fash io n ("W hich w ould you rather have— th e secu ­

rity th at c o m e s from h a v in g s o m e o n e else a ro u n d w h o cares for
you or the freed o m o f b e in g single b u t perhaps so m ew h a t lonely?")
I h e latter typ e o f qu estion , repeated o v e r a w ide range o f topics,
ev en tu a lly leads to the co n stru ction o f a p erson al hierarchy. For
exam p le, th ro u g h th e follow ing series o f q u estio n s arid answers, it
b e c o m e s clear that the client valu es freedom m o re t h a n w ealth , and
w ealth m o re th a n person al relationships:

Questions Answers

W h ich do you prefer:

• W ealth o r pop ularity? W ealth

• Security or in d e p en d en ce? In d ep en d en ce
• W ealth o r in d ep en d en ce? In d ep en d en ce
• Lots o f friends o r w ealth? Wealth
• H ealth or lots o f friends? Friends
• Friends or y o u r in d e p en d en ce? In d ep en d en ce
• Being paid well o r b e in g th e boss? Being the boss

T h e th erap ist shou ld b e mindful that th ou gh this q u estio n in g tech­

n iq u e can b e useful, it does h av e its limitations. Clients will be
tem p te d to provide an answ er that they th in k th e therapist wants
to hear. After u sing the q u estio n s in developing a basic hierarchy,
elicit in fo rm a tio n from y o u r clients ab o u t th eir past and present
attitudes and exp eriences, w hat th ey have actually d on e and thus
actu ally believe. S ee if th ese con firm their reported value prefer­
ences. A h ie ra rc h y can also b e d ev elo p ed b y u sing a Q -s o rt tech­
n iq u e o r fan tasy an alog ies sim ilar to such g am es as "G en ie in a
Bottle" o r "Three Wishes."
2. M a k e a list o f old, d am a g in g beliefs and have y o u r clients associate
e a c h o f th ese w ith a particular v a lu e o n their personal hierarchies.
(Any beliefs th a t d o n 't fit o n th e h ierarchy are im m ed iately high­
lighted as b e in g in c o n g ru o u s w ith clients' realities.)
3. M a k e a list o f the new, preferred beliefs and ch allen g e you r clients
to asso ciate e a c h o f th ese with a particular valu e o n th eir personal
hierarchies. T h ose new' beliefs th a t can clearly b e ju x tap osed to
hig h er values th a n th e contrary, old er beliefs are highlighted. The
clients sh ou ld th e n practice perceiving th e h ig h e r v a lu e w h en ev er
th ey th in k o f th e new belief.
4. For repetition, h av e clients practice seein g th e higher valu e in a
264 T h e N ew H a n d bo o k of C o g n i t iv e T j i e r a t y T e c h n iq u e s

variety o f situations. This ca n b e d o n e by u sing im ages in th e c o u n ­

seling ro o m o r b y w aiting until an e n v ir o n m e n ta l stim u lu s triggers
the thought.

E x a m p les
Old belief: It w ould b e very b ad if m y h u sb a n d 's co lleag u es did not
a pprove o f me. .
Higher client value: Christian religious beliefs.
New belief: To truly follow Christ's teachings, don 't strive to b e p o p u lar
and appeal to w hat p e o p le think. M o r e im portantly, C hristians shou ld
use their G o d -g iv e n in n er c o n s c ie n c e and b e true to His principles.

Old belief: Everything I try to do end s up in failure.

Higher client value: E nd uran ce, "W h e n th e g o in g gets tough, the tou gh
get going!"
N ew belief: I am not in con trol o f w h e th e r I su cceed o r not. I a m o n ly
in con trol o f m y trying. I will alw ays strive and try to learn from m y
failures so that I can b e m o re successful in fu tu re attempts.

Old belief: I am to b la m e for m y fa th er sexu ally a b u s in g me.

H igher client value: D o m in an ce, control, and com p etition .
New belief: If I keep eating m y self up w ith this irrational guilt, I lo se and
let the bastard win again.

Old belief: Sh e left m e for a younger, m o re successful man.

H igher client value: W h a t is o b je ctiv e ly true.
New belief: I'm g oo d , b u t I am not b etter th a n all th e o th e r m e n in the
world.

Old belief: I m u st h av e a m a n in ord er to b e happy.

H igher client value: Self-respect.
New belief: I w ould rather like m y s e lf a lo n e th a n h a te m y se lf living as
a slave to a m a n I disliked.

Old belief: If 1 take this jo b abroad, I'll leave all m y friends.

Higher client value: Stim u lation an d variety.
New belief: I w ould die o f b o r e d o m here s o o n e r t h a n I'd die o f loneli­
ness there.
Perceptual Shifting: Bridging 265
/

C om m en t
As th e ex a m p le s illustrate, it is crucial th a t therapists r e m e m b e r that
th ey are bridging o n th e client's v alu e system, n ot th e therapists'. It
d oesn t m a tte r w h at th e therap ist th in k s o f the client's values, it's what
th e client thinks th a t counts.
In m a n y cases it is difficult to find the client's tru e values. T h e ther­
apist m u st ta k e particular ca re to lo o k for values th a t the client rejects
in th e therapist's p resence b ec a u se they are socially unpopular, i.e.,
h ed o n ism , power, etc. Differences b etw een stated values and actu a l
o n e s can b e discovered b y e x a m in in g clients' histories.
As an aid in h elp in g clients visualize th e su periority o f th e new
b e lie f o v e r th e old, I h a v e devised a th r e e -c o lu m n w orksheet o n which
clients are asked to record their valu es in hierarchical order (colum n
# 1 ), th eir old beliefs (co lu m n #2), a n d th e proposed new beliefs (col­
u m n #5), w ith each b e lie f ju x ta p o sed to the value from w hich it
derives (see tab le 9.1). A pplying this w o rk sh eet to o u r earlier example,
th e client m ig h t see that an a ll-c o n su m in g quest for w ealth that
deprives him o f certain freed om s in life is clearly con trad ictory to his
h iera rch y o f values.
Therapists m ay a sk their clients to con stru ct their ow n w orksheets
to period ically con firm , o n th e basis o f their ow n self-analysis, that
th ey are o p era tin g a ccord in g to their highest values. Such periodic
reassessm en ts ca n b e useful, since values can c h a n g e abrup tly or over
a p erio d o f time. T he client w h o suffers a n ear-fatal heart attack m ay
s u d d en ly find h im s e lf re -ra n k in g his values in preference for those
that place g rea ter e m p h asis u pon th e qu ality o f his life.

T a b l e 9 .1
Heirarchy o f Values Worksheet

Rank Order of Values Value of Old Belief Value of New Belief

1. _________________________________________________________ ________________________________________________________ __________________________________________________

2. _____________________ __________________
3. _____________________ _____________________ __________________
4. _________________________ _________________________ _______________________
5. _____________________ _____________________ __________________
6. ________________________ ________________________ _____________________
7. _________________________ _________________________ _______________________
8. _____________________________________ _____________________________________ ________________________________
9. _____
10 .
266 T u t N tw H and bo o k or Coc.Ninvt TtitRArv TteiiN iuuts

F u rther In fo r m a tio n
Research on attitude c h a n g e has d e m o n strated th e im p o rta n c e o f
th e value c o m p o n e n t o f people's beliefs (see Flem m ing, 1967; Petty &
Cacioppo, 1981; Rokeach, 1964, 1968, 1973, 1979; and Sm ith, Bruner, &
W hite, 1956). Theoretically, valu e shifting can b e view ed as a n o th e r
in stan ce o f Premack's principle (Premack, 1965).
Personal valu es h av e so m e o f the stron gest se lf-re fe re n c e effects
(SRE) (see Banaji & Prentice, 1994; Bellezza & Holt, 1992; K eenan,
Golding, & Brown, 1992; and Rogers, Kuiper, & Kirker, 1977).

L a b e l B r id g e s

Principles

A single w o rd or s y m b o l m a y serve as a bridge. Each w o rd and

sy m b o l has a c o n n o ta tiv e as well as d en o tativ e m e a n in g ; e a c h collects
em o tio n a l resp on ses th ro u g h operant, classical, o r co g n itiv e c o n d i­
tioning. O n c e a sy m b o l and affective resp o n se h av e b e e n paired, the
sy m b o l has the cap acity to elicit th e e m o tio n directly.
Sym bols are by definition arbitrary', indicating only a con sen su s
a b o u t what som eth in g m e an s; usually o n e s y m b o l can su b stitu te for
a n o th er qu ite easily. T he exception to this generalization is fou n d in
certain words. Thou gh w ords m a y easily en o u g h b e su bstituted for
o th er words, different words often carry totally divergent em o tio n a l
conn otation s. M a n y clients con sistently c h o o se w ords w ith negative
c o n n o ta tio n s w h en they could ju st as easily select neutral or positive
labels.
Label bridging helps clients iden tify th e ir negative lab els and shift
th em to m o re objective, positive, em o tio n a l asso ciation s. T h ey learn in
this process that the o n ly difference b e tw e e n s o m e w ords a n d others
is their em o tio n a l valence.

M eth o d 1. Word L a b e ls
1. M ake a list o f th e specific ev en ts o r situ a tio n s (referents) th a t the
client associates with negative w'ords. For instance, w h a t referents
does the client visualize w h e n u sing th e w ords "inferior," "sick," and
"weak"?
2. D escribe these referents in ob jective, n o n e v alu a tiv e term s. W h at
would a m o tio n -p ic tu r e ca m era record o f th e ev en t o r situ ation ?
Perceptual Shifting; Bridging 267
/

W h a t w o u ld a n o b je c t iv e th ird p a rty o v e r h e a r?
3. List th e m a jo r negative labels the client uses to describe th e situa­
tions.
4. H elp th e client list th e n eu tra l and positive labels that could b e
used to interpret th e referents. Explain h ow these n ew labels are
ju st as valid as previous labels, b u t can bridge to m ore positive
em otio n s.
5. H ave th e client practice u sing n ew labels ever)' day, recording the
situation, finding th e n eg ativ e lab el for it, and bridging to a m ore
positive word.

E x a m p le
A person w ho . . . Could he called . . . Or could be called . . .
c h a n g es o n e 's m ind a lot w ish y -w ash y flexible
exp resses o n e 's o p in io n egotistical genuine, assertive
is e m o tio n a lly sensitive hysterical, fragile alive, caring, open
is selective in c h o o sin g afraid to com m it discrim inating
a m ate
gets d epressed so m etim es neurotic h u m an
isn't g o o d at a gam e klutz, inferior hasn't practiced
isn't orderly sloppy, piggish sp ontaneou s,
carefree
pleases others social p h ob ic friendly
b eliev es w h at o th ers say gullible trusting
loves a n o th e r strongly d ep en d en t loving
gets an xiou s weak, cowardly aware
is n o n tra d itio n a l anarchist, free-spirited,
heretical, im m oral self-reliant
is h elp ed by a n o th e r m anipulated cared for
is n o t w o rk ing hard lazy relaxed
o n a task
is su re o f so m eth in g conceited self-confid ent
lo o k s at things positively Pollyanna optimist
talks a lot m o to r -m o u th expressive
thinks b e fo re m ak in g indecisive prudent
decision
takes risks foolh ard y brave
sticks to projects bullheaded resolute
gets excited hysterical ex u b e ra n t
268 T h e N ew Han d bo o k of C o g n it iv e T h e r a p y T e c h n i q u e s

V v

M eth o d 2. S y m b o lic L a b e ls
A sy m b o lic la b el can b e esp ecially effective for certain clients, par­
ticularly th o se w h o have a stro n g religious orien tation . Richard Cox
has develo ped a p roced u re u sing sy m b o ls a n d rituals to b rid g e fro m
old to new beliefs (Cox, 1998). W e h av e m od ified th e p ro c e d u re to
em p h asiz e the cogn itiv e elem en ts involved.

1. Identify th e b e lie f cau sin g the problem . (Cox calls it th e "demon.")

2. Help y o u r clients to find a personal s y m b o l th a t rep resen ts th e
p rob lem area. T h e sy m b o l needs to b e deeply, e m o tio n a lly rooted
in th e client's history. (For exam ple, a w o m a n w h o b elie v ed h erself
trapped in an ab u sive m arriage im m ed iately th o u g h t o f th e sy m b o l
o f th e crucifix. Sh e felt it rep resented h e r sacrificing h e r s e lf in ord er
to keep h e r husband.)
3. Help clients identify the positive o r p ro m o tiv e belief. ("I n ee d to
leave.")
4. Assist clients in fin d in g a specific s y m b o l th at will b rid g e th e d a m ­
aging b e lie f to th e prom otive. No sy m b o l is to o e x tr e m e a n d the
therapist doesn't need to u n d erstan d w h y it is im p o rta n t as long as
the client understand s it. (In o u r exam ple, th e clien t th o u g h t o f h e r
ow'n resurrection; sh e pictured h e r t o m b b e in g o p e n e d up an d her
w alkin g o u t into th e bright sh im m erin g sunlight, aw ay from the
marriage.)
5. Have clients practice associating th e tw o sy m b ols. Start w ith the
sy m b o l o f th e p rob lem area and have clients shift to th e s y m b o l for
the p ro m o tiv e belief. (Ever)' tim e o u r client th o u g h t o f h er m arriag e
b e in g like a crucifixion sh e practiced shifting to th e s y m b o l o f a res­
urrection. It was not lo n g b efo re s h e saw th a t sh e w as not trapped,
th at sh e didn't h a v e to sacrifice h erself o n th e cross o f h e r h u s ­
ban d's abuse, and that s h e was free to "w alk into th e su nlight"
w h e n e v e r sh e wished.)

C om m en t
S o m e clients m ay argu e that a negative w ord is m o re logically co r­
rect than a positive w ord; for exam ple, o n e clien t suggested that
w ish y -w a sh y p eople c h a n g e th eir m ind s m o re o ften th a n flexible
p e o p le; th erefo re, w i s h y - w a s h y is a m o r e a c c u r a te descriptor.
A lthou gh there m ay b e so m e c o n cre te differences b e tw e e n sy n o n y m s,
m a n y differences are purely, reflective o f o u r v a lu e system s. W e refer
to p eople as w ish y -w a sh y b e c a u s e w e th in k th ey c h a n g e th e ir m ind s
Perceptual Shifting; Bridging 269.
/

m o re t h a n w e th in k th e y sh ou ld — n ot b ec a u se th ere is so m e objective
stan dard o f h ow often p eople are perm itted to switch their opin ions
an d still b e called flexible. Likewise, w h en w e call s o m e o n e "lazy" w e
m a y th in k th e y are u n n ecessarily idle. Bui since ev ery on e is doing
s o m e th in g (sleeping, resting, thinking, playing, etc.) w h at w e really
m e a n is th at they aren 't d o in g w h a t we th in k they o u g h t to b e doing.
If clients pick the right sym bols, sy m b olic bridging can produce
in stan tan eou s and dram atic shifts that m ake p erm an en t changes. How­
ever, b o th sy m b o lic a n d w ord bridging are rarely used alone. M ost fre­
qu en tly th ey are an a d ju n ct to o th er cognitive restructuring approaches.

F u rth er In fo r m a tio n
Frijda, M a rk a m , Sato, a n d VYiers (1995) discuss the im p o rta n ce o f
w o rd labels and th eir ability to elicit e m o tio n a l reactions. T h e " R u m -
plestiltskin effect" describes the d ram atic ch a n g es that can ta k e place
b y sw itch in g th e w ords clients use to describe their problem s (see T or-
rey, 1972). S y m b o lic bridging can b e best u nd erstoo d b y reading Cox
directly (see Cox, 1975, 1998).

H ig h e r - o r d er B r id g in g

Principles

S o m e clients do n ot h av e a sufficient n u m b e r o f a n ch o rs in their

ow n rep ertoire to serve as bridges from the old b e lie f to the new. For
su ch clients th e therapists can create bridges using the principles o f
h ig h e r -o r d e r covert conditioning.
In classical learnin g theory, h ig h e r-o rd e r co n d itio n in g pairs neutral
stim uli with a n o th e r ele m e n t th a t is already conditioned. For example,
a fla sh in g red light (CS-1) can b e paired with relaxation (US), prod u c­
ing a calm resp o n se (CR). If the e x p e rim en ter then associates a bell
w'ith the red light, th e b ell (CS-2) a lo n e can elicit the CR.
Sch e m atica lly it can b e rep resented as:

Original Conditioning

U R (calmness)
270 T he N ew H an d bo o k of C o g n i t iv e T h era py T e c h n iq u e s

Higher-order Conditioning

|— C S—2 (bell)

paired

^ U C S - 1 (red light)

W ith sufficient pairing, a n y variab le percep tible to clients can b e a

C S -2 and serve as an a n c h o r for la ter bridges. C ognitive restru ctu ring
gen erally uses tw o types o f variables— p ercep tio n s and con cep tion s.
Perceptions are m a d e u p o f visual, auditory, olfactory, a n d k in esth etic
representations. C on cep tion s are beliefs, thou gh ts, a n d attitudes.
H ig h er-ord er b rid gin g involves takin g the p ercep tu al an d co n ce p tu a l
C S -2s associated with the new b e lie f a n d pairing th ese with th e old
belief. After a series o f repetitions, th e old b e lie f b e g in s to bridge
toward the new.

M eth o d
1. Have th e client focus on th e old b e lie f and create a m o d e l o r typi­
cal scen e w h e re this old b e lie f o ccu rs strongly. T h e sc e n e sh o u ld b e
im agined in vivid detail, using all th e senses.
2. Record in w riting all th e perceptual a n d co n ce p tu a l v a ria b les (C S-
2) co n n ected with the image.

P ercep tu al
a. Visualization. W h a t th e client pictures in th e sc e n e is dissected in
great detail. For exam ple, is th e scen e in color? Is it a still or
m o tio n picture? clea r o r fuzzy? t w o - or th r e e -d im e n s io n a l? Is th e
client seeing h erself in the scen e? W h a t is th e focal p o in t (the
m a jo r ele m e n t in th e scen e that draw s th e client's atten tion )? Is
th e scen e bright or dim ? W h a t is the an g le o f view ? W h a t is the
size o f th e client in relation to o b je cts th a t fo rm th e b a ck g ro u n d
o f this scen e? Are th e p eople m oving?
b. Other senses. Auditor)'— c a n the client clearly h e a r th e sou nd s?
W h a t is their du ration? How loud are they ? O lfactory— w h at
does the client smell? 'K inesthetic— w h a t is th e te m p era tu re ? etc.
 Perceptual Shifting: Bridging
/

C o n c e p tu a l
a. Every m a jo r th ou gh t th a t th e client has before, during, and after
th e im a g in e d e v e n t is recorded. T h e therapist helps th e client to
state th ese th ou g h ts explicitly. T he typ es o f th ou g h ts to look for
are:

i. Expectan cy— w h a t the client anticipates will h a p p e n in the

situation.
ii. Evaluation— th e a ssessm en t that the client m akes o f h erself
du ring the scene.
iii. Self-efficacy— t h e client's ju d g m e n t o f his ability to com plete
th e task effectively.
iv. Payoffs— the anticip ated rew ard o r p ay off the client thinks
h e will get in th e situation.
v. P u n ish m e n ts— the aversive things th e client anticipates.
vi. S e lf-c o n c e p t— th e client's attitudes a b o u t his o r h e r w o rth as
a h u m a n being.
vii. A ttributions— the attitudes and m otivation s the client attrib­
utes to others in the scene.
viii. Pu rp ose— w h y th e client is in th e scen e in th e first place.

b. T h e th erap ist also searches, a lo n g w ith the client, for logical fal­
lacies th at m ight surface in the client's interpretations o f these
scenes. Each fallacy' is written down. T he m ost c o m m o n fallacies
are: d ic h o to m o u s thinking, overgeneralization, n o n p arsim o n io u s
reasoning, perfectionism , reification, su b jectiv e error, argu ing ad
h o m in e u m , ipse dixit, a priori thinking, finding the g o o d reason,
e g o ce n tric error, self-fulfilling prophesy, m istak in g prob ab ility
for possibility, etc. (see section on logical fallacies in ch ap ter 6).
3. After recording all o f th e perceptual and c o n ce p tu a l inform ation
c o n n e c te d to the old belief, the therapist asks the client to picture a
s c e n e c o n n e c te d with th e n ew belief— th e o n e that w e wish to
b ridge to. It shou ld b e a m odel scene, o n e that represents the new
b e lie f ideally. T h e closer the c o n te n t o f th e new scen e is to th a t o f
the old scene, the better. Like the first scene, this im age shou ld be
pictured in great detail, until it is vivid.
4. As in step #2, record all o f th e perceptions th e client has o f th e new
s c e n e — visual, auditory, an d kinesthetic. Point o u t to th e client the
c on trast b etw e en th e tw o ways o f view ing th e im age as the list is
developed .
5. T h e c o n ce p tio n s o f th e new sc e n e are likewise recorded. T he thera­
pist sh o u ld pay carefu l atten tion to finding th e attributions, e x p e c­
 T i i l N e w H a n d b o o k or- C o g n it iv e T h e r a p y T e c h n iq u e s .

tations, self-con cep t, an d ev a lu atio n s th e client m ak es in th e new

scene. T he therapist writes d o w n th e c o rrect reaso n in g th e client
has in the visualization.
6. T h ere is a pau se in th e im agery work. T herapist an d client discuss
the differences b e tw e e n the perceptual a n d co n ce p tu a l rep resen ta­
tions o f th e tw o scenes.
7. Now th e therapist is read y to d o th e actu al h ig h er o rd e r c o n d itio n ­
ing. T he client im agines th e original scen e for tw o m inutes. G radu ­
ally, th e therap ist in tro d u c es th e p e rce p tu al an d c o n c e p tu a l
represen tations o f th e new scene, o n e at a time, w ith th e client
im ag in in g th e ch an g es until they are vivid. T he process co n tin u e s
until all the e le m en ts from th e new sc e n e are incorp orated . W h e n
this is successfully don e, th e client is a b le to im a g in e th e old scene,
b u t with all th e perceptual and co n ce p tu a l c o m p o n e n ts bridged to
th e n ew scene.
8. O ften the w h o le p roced u re is record ed on tap e so th a t th e client
c an practice th e co n d itio n in g two to th ree tim es a week. W ith
e n o u g h pairings th e em o tio n a l v a len ces o f th e scen es sw itch and
the client is far m o re likely to b eliev e in the n ew thought.

E x a m p le : The Story o f Alex

Alex, a n attractive y o u n g m a n in his late twenties, h ad difficulty
m eeting w o m en . A lthou gh he'd had several lo n g -te r m successful rela­
tionships, th ey had all b e e n initiated b y th e w o m en . He co u ld n 't intro­
d u ce h im self to eligible, attractive w o m en , despite h a v in g m em orized
b o o k s o n h ow to m eet w o m e n and ta k en classes o n th e art o f c o n ­
versation.
His old, n egative visualization revealed his p rob lem . H e d escribed
him self in a singles' bar, stan d in g close to a v ery attractive w o m a n . He
visualized h im s e lf as a p p e a rin g very sm all w h ile all th e o th e r m e n
tow ered o v er h im (he was 6' 1"). T he w o m a n w as th e focus o f th e scene;
sh e was very colorful w h ile h e w as dull an d m uted. H e pictu red a
spotlight illu m in atin g h e r w h ile h e sto o d in th e shadow s. Sh e was
m o v in g in his sc e n e w h ile h e was as rigid an d still as a figure in a
snapshot. K inesthetically s h e seem ed cool a n d icy w h ile h e felt hot
and itchy.
His cogn ition s revealed ev en m ore:

Purpose: to im press her.

Expectancy: "I will fail miserably."
Perceptual Shifting: Bridging 273

Self-concept: "I am an inferior male."

Efficacy: "I will fail w h en I try to talk to her."
Attribution: "Sh e will despise m e and th in k m e a creep."

Logical fallacies w ere n u m ero u s:

Catastrophizing: "It w ould b e terrible if sh e rejected me."

Overgeneralizing: "If sh e rejects me, all w o m en will."
Perfectionism: "I m u st lo o k like the perfect male."
Pathology: "I m ust b e really sick to h av e this problem."
Traitism: "I h av e th e 'w ron g stuff”'
M usturbation: "I m u st get her to like me."
Egocentric error: "If I talk to her, sh e will focus all o f her a tten tio n on
m e an d will inspect m e for a n y flaws."

H e easily d ev elo p ed a visualization o f a new scene representing a

n ew belief. He pictured h im s e lf in th e sa m e b a r talking to a group o f
m en. It had recently happ ened . He was th e cen ter o f attention and
e n jo y e d telling jo k e s a n d stories. T h ere w ere no w o m en around.
In his visu alization h e was th e sam e size as the others. Everybod y
w as in focus, colorful an d in m otion . Kinesthetically, h e felt w arm and
pleasant.
H e also th o u g h t qu ite differently in his new' scene:

Purpose: to have fun talking to th e men.

Expectancy: n one, "I'll e n jo y this as m u ch as I can."
Attribution: "W h o cares w h a t th ey th in k o f me. It doesn't really m at­
ter?'
Self-concept: "M y w orth as a h u m a n b e in g is not involved in this in
a n y way."
Evaluation: "I'm m o re interested in talking to th em and finding out
w h at th ey th in k th an in how I c o m e across."
Efficacy: "I can talk to m e n w ith o u t any problem . If the conversation
doesn't w ork it's m o re likely to b e their difficulty th a n mine."

Instead o f th in k in g in term s o f logical fallacies, h e was very realis­

tic:

Com m onplace expectations vs. catastrophizing: "No big deal, I don 't need
th em to like me."
Discriminating vs. overgeneralizing: "Even if they don't like me, m any
o th e r m e n will and do."
R ealism vs. petfectionism : "There is no reason for m e to try to d o any­
th in g perfectly in this situation. I'll ju st act n orm ally and they can
 The N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

take it o r leav e it."

Health vs. pathology and trail ism: "W h a t I am d eep d ow n in sid e is
totally irrelevant w h ile talking to th e se m en. I'm ju st trying to h a v e
a pleasant conversation."
Nonchalance vs. m astu rbation : "I e ith e r will like th e c o n v e rs a tio n o r I
won't. There are no musts, oughts, o r shoulds."

W e now h a d two lists o f C S-2s: th o se c o n n e c te d to th e old sc e n e in

w hich Alex was u n a b le to a p p roach th e attractive w o m an , a n d those
c o n n ected to th e new sc e n e in w h ich he was talking with m en. To use
h ig h e r-o rd e r conditioning, w e had Alex picture th e old sc e n e w ith th e
p ercep tion s and c o n ce p tio n s previously associated with th e new
scene. This w ould e n a b le Alex to bridge from th e old to th e new. T he
follow ing w as th e b e g in n in g instruction.

Okay, Alex. Now I w ould like y ou to relax again. N arrow y o u r

atten tion and focus o n y o u r muscles. M a k e th em loose, limp, and
slack. (2 m inutes)
That's fine. Now please recreate th at first scen e w h ere y o u felt
so tense. Im ag ine right n ow that you are in th e b a r and th e sam e
attractive w o m an is stan d in g close by. Picture it as vividly and
clearly as you can in th e s a m e w ay you did before. D on't c h a n g e
anything. S ee it in th e s a m e way. W h e n it's clearly in m ind , indi­
cate b y raising y o u r finger. (2 m inutes)
Keep im ag inin g the image, b u t I would like y ou to gradually,
at m y direction, m a k e ch an g es in w hat you see a n d think. First,
picture that y ou are o f th e sa m e size as th e o th e r m e n in the bar.
Im ag in e that until it is clearly in m ind, and indicate w h en you
are ready. (1 m inute) Now keep visualizing y o u r larger size b u t
add m otion and co lo r to yourself. Picture that y o u are m o v in g
ju st like the attractive w o m a n , and th a t y ou are e q u a lly colorful.
(We c o n tin u e d sw itch ing all the o th e r p ercep tio n s from th e n ew
scen e to th e old scene.)
That's good. Keep visualizing and feeling th e scen e in th e new
way that you have ju st practiced, b u t n ow I w ould like y o u to
im ag in e saying different things to y o u rse lf in th e scene.
First picture y o u rse lf lo o k in g at her, b u t instead o f th in k in g
that y o u r p u rp o se is to try a n d im press her, im a g in e th a t y ou are
thin kin g o f h e r in the s a m e w ay you th o u g h t a b o u t talking to the
m en. Im a g in e thinking that y o u r p u rp o se is to h a v e fun talking
to h e r rath er th a n im pressing her. Visualize this until it's clearly
in mind. Indicate w h en yoti are finished (1 minute). Now, picture
Perceptual Shifting: Bridging 275
/

th in k in g that th ere are m a n y o th e r w o m en you can talk to if this

c o n v e rs a tio n d o esn 't w o rk out. (We c o n tin u e d sw itching all the
o th e r c o n c e p tu a l C S -2 s fro m the m astery scen e to th e negative
scene.)

T h e session was tap ed and th e client listened to the tape th ree tim es
a w e e k for a b o u t six weeks. He reported that with each succeeding
w e e k h e found it easier and easier to approach attractive w om en.

C om m en t
For b rid gin g to take p lace th e p erceptual a n d conceptual aspects o f
th e n ew sc e n e h av e to b e stron ger th a n those o f the old, o therw ise the
o p p o site c o n d itio n in g c o u ld occur. In addition, th ere m ay b e other
p ro b le m s with h ig h e r-o rd e r conditioning. Pavlov's w ork indicates that
th e farther aw ay the CS is from th e US, th e sm a ller the amplitude, the
lo n g e r the latency, and the less p e rm a n en t th e CR response. T he CRs
ha v e a te n d e n c y to extingu ish quickly. However, th e cognitive elem ent
m ay b e a crucial addition to th e conditioning. C onceptu al ch a n g e may
h elp clients m a in ta in w h at would o therw ise b e weak, h ig h er order
associations.

Further In fo r m a tio n
S k in n e r (1955, 1974) and Pavlov (1928, 1960) did the germ inal w ork
o n h ig h e r-o rd e r conditioning.
EiVlDR a n d NLP practitioners use h ig h e r-o rd e r co n d itio n in g in
m a n y o f th eir tech n iqu es. E y e -m o v e m e n t training and "restructuring"
m a y b e b ased on h ig h e r-o rd e r conditioning. Both approaches use
cogn itiv e m od ification, b u t th ey are not as central to th eir m e th o d s as
t h e y are to cogn itiv e therapists. S ee S h ap iro (1995, 1998) for the origi­
n al EM D R , an d Lohr, K leinknecht, Tolin, and Barrett (1995) for a criti­
cism. For NLP see B and ler (1992, 1996), Bandler and G rinder (1979,
1996), Dilts, Grinder, Bandler, DeLozier, and C a m e ro n -B a n d le r (1979),
G rinder and B a n d ler (1975, 1982).
S o m e b a sic research o n h ig h e r-o rd e r co n d itio n in g m ay b e found in
K elleher (1966), Rizley a n d Rescorla (1972), a n d Stu b bs a n d C ohen
(1972).
 Historical Resynthesis

B e l ie fs a n d a t t it u d e s h a v e a lo n g history; th e y do n ot s im p ly a p p e a r
overnight. T he cognitions that clients h av e to d ay are o n ly th e m ost
recent rein ca rn atio n o f beliefs that m a y h av e origin ated m a n y years
before. A lm ost all beliefs h a v e a d e v elo p m en ta l h isto ry th a t stretches
into the distant past. O ften th e roots o f a p resent c o g n itio n are m o re
in form ative th a n the con ten t. M a n y tim es an attitude m ay h av e b e e n
o n c e useful and a ccu rate w h en it was first form ed b u t has lo n g sin ce
b e c o m e anachronistic. C onsider th e Figure 10.1, w h ich rep resents th e
historical d e v elo p m en t o f clients' beliefs. T he dots stand fo r raw sen ­
sory data enterin g th e brain; the data m ay c o m e from a client's senses
(seeing, hearing, tasting, touching, smelling), th ey m ay b e so m a tic (a
physical se n sa tio n from th e body, such as a h u r t elb o w o r a stuff)'
nose), o r th e y m ay c o m e from e m o tio n s (sadness, anger, o r fear). T h e

/\
• \ \ •

A
' \

•V
# t
¥

Child Pattern Adolescent Pattern Adult Pattern

F i g u r e l f o . l D is to r te d life t h e m e s
HistoricaUksypihesis__________________ ___________________________________________ 217
/

data are disorganized, and d o n 't h a v e m e a n in g until the b ra in groups

th e m into a n organ ized pattern.
If clients' b rain s w ere com pu ters, ev ery b o d y 's data would be
g ro u p e d in to th e s a m e patterns: a triangle for th e first pattern, a cir­
cle for th e secon d , an d a sq u a re for th e third. But h u m a n brains don't
sim p ly sca n data— th ey tran sform it. T h ey create patterns based on
hab it an d e m o tio n s and w h a t o th e r brains have ta u g h t them . As chil­
dren clients m ay perceive triangles; as th ey grow, they m ay co n tin u e
to se e triangles ev en th o u g h circles o r squ ares provide a b etter fit.
Clients can sp e n d their en tire lives seein g triangles sim ply b ecau se
th e y first saw t h e m w h en they w ere young.
C om p uters don 't m a k e this typ e o f mistake, b u t h u m a n s do all the
tim e. For exam ple, as children, clients m ay lo o k at the raw data o f
them selv es and th e world a n d form th e pattern that they are w eak
and sm all (the triangle)— this pattern is accu rate at that stage in their
d e v elo p m en t. As th ey get o ld er th e raw data ch ange; they are less
w e a k a n d pow erless (the circle and square), but m a n y clients co n tin u e
to se e the triangle an d c o n tin u e to th in k o f them selves as w e a k and
powerless.
Early tra u m a tic learning, b ad teaching, or em o tio n a l distu rbance
m a y p reclu d e s o m e clients' progression to new ways o f transform ing
data. T h ese clients con sisten tly organize their exp erien ces into tw o dif­
feren t types o f them es: d a m ag in g o n es that o n c e reflected th e world
a ccu ra tely b u t w h ich b e c a m e irrelevant as th e world changed, or
th e m e s th at w ere always false and distorted. In eith er case, th ese ear­
lier th em e s cau se clients m u ch distress and therefore n eed to be
rem oved. In th ese cases, clients' problem s are n ot treated simply by
c h a n g in g th eir present d a m ag in g beliefs. T h e therapist also n eeds to
re m o v e th e historical m isinterpretation th at originally generated the
distortion.

R es y n t h esiz in g C r it ic a l L ife Ev en ts

P rin ciples
R em o v in g th e historical roots o f clients' m isp erceptions has proven
to b e a successful rem edial strategy for m ost clients. Hence, today's
cogn itiv e therapists are m u ch m ore likely to in corp orate tech n iq u es
that a cco m p lish this as a standard part o f their th erap eu tic repertoire.
Past critical life ev en ts often forge m isperceptions. Because clients have
278 T h e N e w H a n dbo o k, op C o g n it iv e T h era py T e c h n iq u e s

stored th e se ev en ts in th eir m em ories, they o ften n ee d to c o rrect the

cognitive m istakes m a d e du rin g the earlie r critical ev en t in o rd e r to
shift their present thinking.

M eth o d
1. Relax the client.
2. Use th e lists o f critical ev en ts you h av e c o m p iled (see c h a p te r 5).
3. At tim es you will find it m o re ap p rop riate to su b stitu te m o re sp e ­
cific lists fo r gen eral ones. T he specific lists recou nt the key events
linked to the client's sym ptom s. For exam p le, if clients are anxious,
th e n have th em write th ree lists o f th e key a n x ie ty attacks th e y have
had— o n e for ch ild h ood , o n e for adolescen ce, a n d o n e for adult­
hood. Or, w h en w orking with delayed stress sy n d rom e, e m p lo y
th ree o th e r lists: p re -tra u m a tic event, d u rin g tra u m a tic event, and
p o st-tra u m a tic event.
4. Suggest that y o u r client d e scrib e th ese critical ev en ts in detail.
5. After discussion with y o u r client, ascertain w h e th e r a n y o f the
beliefs that were created b y th e critical ev en ts still c a u s e p ro b lem s
in th e present.
6. Also discuss h ow th e client's e m o tio n s and b e h a v io rs altered
b e c a u s e o f th e beliefs form ed at th e tim e o f th e critical events.
7. Help y o u r clients to reinterpret the old ev en ts with new, m o r e use­
ful beliefs. H ave th em scrutinize the ev en ts with th e a d v a n ta g e o f
d istance and tim e so that th ey c a n rectify earlier m istak en p e rce p ­
tions w ith adult reasoning.
8. Use corrective c o p in g im a g ery so th at y o u r clients can revise th e
event b y im a g in in g th a t they had th o u g h t an d acted reasonably.
9. Review all m a jo r critical ev en ts; detect th e b e lie f and h av e th e client
im ag in e correcting the situation.

E x a m p le 1: The Story o f M ark

M a rk was se n t to m e b y a n o th e r cognitive therapist. He w as suffer­
ing from a g o ra p h o b ia, had seen several different therapists o v e r five
years, and had m ad e so m e progress. He was c a p a b le o f traveling m ost
places and p erform in g m ost activities w ith o u t u n d u e fear, b u t in o n e
area h e h ad n 't m astered his fear— h e still co u ld n 't fly. He'd had se v ­
eral in vivo practice session s from a psychiatrist w h o o w n e d his ow n
p lane with n o success. He still hadn't flown.
W e did a c o m p le te analysis o f th e th o u g h ts h e had a b o u t fly ing and
Historical Resynthesis
/

fou n d th em to b e typical for a n agorap hobic. M ark didn't fear the

p la n e c rash in g ; h e was afraid o f getting panicky w h ile airborne. He
feared b e in g trapped o n a plane w h ile h a v in g an a n x iety attack.
His c o r e b e lie f was n ot o u r discovery— previous cognitive therapists
h ad identified it, b u t fo rm e r attem pts at disputing it had not worked.
No o n e h a d p reviou sly identified o r challenged the historical roots o f
his belief, so they w ere still intact. W e decided to ch an g e th ese roots
in o rd e r to shift his c o n te m p o ra ry belief.
M a rk w o rk ed hard and energetically searched for th e historical
fo re ru n n e rs to his present irrational thought. We found the en v iro n ­
m e n ta l trigger for th e se form ativ e irrationalities.
• A ge 2 - 6
Critical event: O verprotected by mother.
Irrational belief: Life is d a n g ero u s an d I need so m e o n e to protect
me. 1 can't h an d le this world by myself.
Corrected belief: M y m o m overprotected m e b ec a u se o f her own
fears, not b e c a u s e o f m y su pposed w eaknesses. Life was no m ore
d a n g ero u s for m e th an for a n y o n e else. 1 can h an d le th e world
as effectively as others.

• A ge 6 - 1 2
Critical event: Spoiled.
Irrational belief: Life sh ou ld b e as easy as it o n c e was.
Irrational belief: I sh ou ld n 't h av e to feel pain.
Corrected belief: Because o f m y early distorted learning, I developed
a false e x p e ctatio n that I shou ld have m y w'ishes fulfilled with­
ou t m u ch effort. This b e lie f is not o n ly false b u t is dam agin g to
me. P eop le h av e to w ork to get w h at they want. The s o o n e r I
learn this, th e h ap p ier I will be.

• A ge 1 2 -1 6
Critical event I: Rejected b y p eers b e c a u s e he acted spoiled.
Irrational belief: It's horrib le if ev ery b o d y doesn't like me.
Irrational belief: If I am perfect I will b e liked.
Irrational belief: I need to con trol everything to b e perfect.
Corrective beliefs: T h e o th e r kids didn't like m e b ec a u se I was a
spoiled b rat and I d em a n d ed th a t they treat m e the way my
o v erp ro tectiv e m o m did— they would h av e n o n e o f this. M y per­
fectionism and attem p t to co n tro l e v e ry o n e was o n e o f the causes
o f th eir rejection rath er th an a correction.

Critical event 2: Saw a fellow stu dent vom it in class an d observed

that his classm ates rejected the student.
280 Th e N ew H a n d bo o k of C o g m t i v e T i ie k a t y T e c h n iq u e s

Irrational belief: People will ‘reject m e u nless I co n tro l ev e ry th in g

physical goin g on inside m y body.
Corrective belief: No h u m a n b e in g can c o n tro l all o f th eir p h y sio ­
logical sym ptom s, m a n y o f w h ich are instinctual. A ttem p tin g to
d o so causes h u ge p rob lem s; I a m sp e n d in g all m y tim e and
en erg y try in g to co n tro l s o m e th in g that can't b e controlled. Peo­
ple are far m o re likely to re je c t m e as a co n tro l freak.

Critical event 3 : Panicked a b o u t g etting sick in a c a r d u rin g a cross­

co u n try trip. Started to fear p an ic itself.
Irrational belief: Now I m u st co n tro l ev ery th in g p sy ch o lo g ical g o in g
o n in m y b o d y so that p e o p le don 't reject me.
Corrective belief: I a m sp e n d in g m y life w a tc h in g m y m in d w ork
instead o f living.

Critical event 4: W h e n e v e r h e con sid ered taking a p la n e trip h e

w o u ld get panicky.
Irrational belief: I w on't b e ab le to co n tro l m y fear in a plane, and
I w on't b e ab le to escape, th erefo re 1 will b e tra p p ed in a n intol­
erab le situation.
Corrective belief: So w hat if I get scared and em b arra ss m y self? It
w ould b e b e tte r i f I did that t h a n sp e n d in g m y w h o le life trying
to control th ese feelings.

E x a m p le 2 : The Story o f R o n a ld
S o m etim e s it is difficult to find th e past critical ev en t c o n n e c te d to
th e present em otion . T h e association m a y b e ob scu re ly linked.
For exam p le, a client from D en v er had a n x ie ty that proved to b e
q u ite a mystery. Ronald was a m id d le-a g ed m a n w h o c a m e to se e m e
b e c a u s e h e w ould o cca sio n a lly h a v e su d d en a n d e x tre m e ly pow erful
p a n ic attacks. Fhese attacks w ould o c c u r o n c e ev ery fou r o r five
m on ths, and the sou rce cou ld n 't b e found. I m ad e a careful list o f all
Ronald's previous a n x ie ty attacks and then used fu n ctio n al analysis
to g ath er a n extensiv e list o f p ossib le causes o r stim u li th a t h a p p e n e d
right b efo re h e g o t anxious. T h e checklist in clu d ed q u e stio n s su ch as:
W ere you angry? S e xu a lly frustrated? W ere you h a v in g p ro b le m s in
y ou r m arriage? Had y ou ch an ged y o u r ea tin g h ab its? W as th e re tro u ­
b le at w ork? Had you b e e n e x trem e ly tired o r d epressed ? W ere you
th in k in g o f so m eth in g that h a d h a p p e n e d in y o u r ch ild h o o d ?
T here w ere m o re th a n 8 0 item s o n his list, an d I h a d used th is te c h ­
Historical Rcsynthcsis 281
/

n iq u e successfully with m a n y o th e r clients. M ost often 1 had found

o n e o r m ore stim uli that alw ays o ccu rred right b efo re the client got
an xiou s, b u t w ould n ev er o c c u r w h en the client didn't get anxious.
But I c o u ld find no asso ciations for Ronald; there w ere n o c o m m o n
triggers fo r his a n x ie ty attacks.
I tried to h elp him an yw ay th ro u g h relaxation training and som e
cogn itiv e exercises, yet I k n e w th at unless 1 fou n d the specific associ­
a tion o r exact stimuli, I could n't effectively treat his anxiety. I was try­
ing to use a sh o tg u n w hen 1 needed a rifle.
Even th o u g h co u n selin g wasn't solv in g his p an ic problem , Ronald
c o n tin u e d th erapy b ec a u se it was h elp in g him in o th e r ways, and
b e c a u s e h e w as curiou s as to w h e th e r w e w ould ev er b e a b le to fig­
u re it all out. But it was difficult. He h a d his attacks so infrequently
that it was hard to find th e cues. Finally, 1 asked Ronald to stop the
sessions until h e had a n o th e r attack a n d then to call— day o r night,
w eek d ay o r w e ek en d — and c o m e to my office.
O n e n igh t several m o n th s later h e phoned m e late at night. He had
ju st had o n e o f his a n x iety attacks. W h e n Ronald cam e to th e office,
h e was still anxious. Now at last, I had th e anxiety sitting in front o f
m e so I could o b serv e it directly.
W e review ed ev ery th in g th a t had h ap p en ed during the day, from
t h e tim e h e had w o k en up to th e lim e he felt th e first pangs o f fear.
W e exp lored his thoughts, feelings, rem em b ran ces, w h a t h e had eaten
th a t day, a n d so on.
W e still d id n’t find a n y triggers— n o th in g significant, no unusual
traum as, frustrations, or conflicts— ju st an average day until the a n x i­
ety attack. W e kept searching. Ronald had b e e n w atching TV, so 1
found a T V G u ide a n d review ed all the show s h e h a d w atched that
d ay to see if o n e o f them m ight have b e e n a trigger, b u t w e found
noth ing. He had read th e m o rn in g p a p e r so w e reviewed the news
stories o f th e day. Still nothing. W e sk im m ed the sports section, the
cartoo n s, th e editorials, th e adv ertisem ents— still zero.
Finally, right b e fo re I was a b o u t to throw th e paper away, I noticed
th e daily w e a th e r forecast. It said an u n u su ally h ig h -p ressu re front
w ould b e c o m in g th ro u g h D enver at a b o u t ten o'clock in the evening.
It stru ck m e th a t this was th e s a m e tim e R onald had b e c o m e anxious.
As a wild guess, I asked Ronald if he'd felt a c h a n g e in th e weather.
R onald said, "Fu nn y that y ou m e n tio n it, b u t I did. I had this eerie
feeling right b e fo re th e panic. I can 't describe it, but it was like the
pressure on m y skin felt different— stron ger o r something."
"H ave you had this se n se o f pressure before"?
282. T u t New H a n d bo o k of C o g n i t iv e T h era py T e c h n iq u e s

He could n't recall exact details, b u t h e did r e m e m b e r feeling this

sen sation before.
Still not sure, I gav e Ronald a h o m e w o rk a ssign m ent. I told h im to
g o to th e library and pull o u t the w e a th e r reports for each o f th e pre­
vious tim es he'd had his a n x iety attacks. I asked h im to try to fin d a n y
c o m m o n feature o ccu rrin g in th em all.
A co u p le o f weeks later h e c o n ta cted me. He was very excited, and
said he'd found o n ly o n e ele m e n t c o m m o n to all th e situations. He'd
discovered that b efo re each o f his a n x ie ty attacks th e b a ro m e tric pres­
sure had b e e n u n u su a lly high a n d th e n u m b e r had b e e n exactly the
s a m e o n each o f these days. Exactly!
It se e m e d strange. How could b a ro m e tric pressure c a u s e panic
attacks? After so m e m o re detective work, w e u n co v ered the e x p la n a ­
tion.
A b ou t 15 years earlier, a critical ev en t had h a p p en ed in Ronald's
life. O n e d ay w h ile at w ork, h e had received a call from a local h o sp i­
tal inform ing h im that his dad had b e e n in an a u to m o b ile a ccid en t
a n d was in critical condition. He was told to c o m e to th e hospital
quickly, that his father m ight not last long. He ju m p e d into his c a r and
rushed to the hospital, pan ic-stricken that h e m ig h t not m a k e it in
time. O n e can guess w h at th e w e a th e r wras— an u n u su a lly h ig h -p r e s ­
su re system was m ov ing th ro u g h Denver. By the tim e h e h ad arrived
at th e hospital, it w as to o late. His fath er had died.
Strange as it m a y seem, th e grief, anxiety, and guilt Ronald had
a b o u t his father's dying w ere associated to th e b a ro m e tric pressure. He
didn't recognize it, b u t his b ra in had c o n n e c te d th e tw o events. Later
on in life, long after th e incident, his b ra in still held th e pairing, so that
ev ery tim e th e b a ro m e tric pressure reach ed ex a ctly (h e s a m e level, it
triggered a p an ic attack.
O n e m ay rea so n a b ly ask w h y th e a n x iety b e c a m e c o n n e c te d to the
b aro m etric pressure rather th a n so m e o th e r stimuli, like th e te m p e ra ­
ture, the tim e o f day, driv ing cars, accidents, hospitals, o r a n y th in g
else. W e don 't know. But s o m e th in g a b o u t th e original in cid e n t m a d e
the b a ro m e tric pressure m o s t 's a li e n t an d m ost receptive to b e in g
paired.
O n ce w e found the c a u s e it w ould h av e b e e n fairly easy to c o u n te r
th e effects b y creating new asso ciation s to b a r o m e tr ic pressure, b u t in
R onald's case w e didn't h a v e to d o that to b r e a k th e pairing. H e did­
n't h av e to practice resynthesizing b e c a u s e he'd found th e trigger, and
the core ol his a n x iety was rem oved. This h a p p e n s w ith m a n y clients
suffering from a n x ie ty attack's. W h e n Ronald realized th e real trigger
Historical Resynthesis 283
/

for his fear, it rem o v ed the thought, "1 am getting an x io u s for no rea­
son. T h ere m ust b e s o m e th in g seriously w ron g with me." This th ou g h t
is o ften a key c o m p a n io n to anxiety. R onald no lon g er gets an xiou s
w h en a c erta in pressure system m oves th ro u g h Denver.
This ca se is a g o o d e x a m p le o f h ow a n y em o tio n can b e c o m e asso­
ciated w ith a n y critical event in u np red ictab le ways. Everything that
t h e b rain is aw are o f can b e paired with any item su rrou n d in g a crit­
ical event. I h av e ob serv ed m a n y stim uli that have b e c o m e con nected :
fur, th e c o lo r red, cloud shapes, acid rock music, full m oons, th e m ovie
Citizen Kane, S o u th A m erican anim als, taking a deep breath, b o o k s on
astron om y , gre en b a th ro o m s, h a v in g a full stom ach, m aking love. In
su ch cases it is useful to help th e client find th e co n n ec tio n s to the
critical event.

C om m en t
M a n y th erap ies ex p lo re the historical routes o f present problems.
CRT differs b e c a u s e o f its e m p h a sis o n the h istory o f clients’ n o n -
ad ap tiv e beliefs. We d o not assu m e that it is necessary or useful to
sy n th esize th e se histories w ith h ig h e r-lev el ab straction s like ego
states, p sy ch osexu al stages o f developm en t, fixation, u n con scio u s
archetypes, regression, or cathexis. Finding the historical origins o f a
p resent b e lie f helps clients to see w h y they th in k as they do, thus
e n a b lin g th em to m ore readily shift th e cognition.

F u rther In fo r m a tio n
G u id a n o (1987, 1991) and G u id an o and Liotti's com p reh en siv e work
(1983) ex p lo re the historical roots o f dysfunctional beliefs. T he devel­
o p m e n t o f PTSD is not o n ly d e p en d en t o n the severity o f th e trau­
m a tic critical event, b u t on th e interpretation o f w h y it happened.
(M o n a t & Lazarus, 1991). Critical events m ay create assu m p tion s about
life that are to o g lo b al to b e useful, e.g., "I must never show any w eak­
ness" (Williams, 1996b).

R esy n th esizin g L ife T hem es

Principles

Critical life ev en ts not o n ly create m istaken beliefs, th ey also help

form life them es. T hese th e m e s tran sform o v e r time an d have th eir
284 T h e N ew H a n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

ow n d ev elo p m en tal history, ju st as o rg an ism s c h a n g e physically. T he

p ow er b e h in d a life th e m e is assessed b y tracing its d e v e lo p m e n t from
th e past. Life them es h av e a vertical depth. Like cogn itiv e trees, they
h av e lon g roots stretch ing back from th e p resent in to th e distant past.
It is useful for th e therap ist to dig up th e roots o f certain c o r e beliefs
in ord er to find the life th e m e b e h in d th em . To illustrate, a present
p erception o f inferiority is d iag ram m ed chron ologically:

• Present: "I a m inferior as a hu sb and , father, and employer."

• Recent past: "I am not a terrific b o y frie n d o r worker."
• Adolescent: "I am a lou sy student, and girls d o n 't like me."
• Young adolescent: "I stin k at sports and o th e r gu ys are a lot to u g h er
th a n me.
• Late childhood: "I a m a bad b o y M y b ro th e r is better"
• Early childhood: "M o m m y and D addy d o n 't like me."

In this ex a m p le th e client's p resent inferiority feelings are rep re­

sented in the past. His earlier m istaken beliefs c o n trib u te to his pres­
ent irrationality.

M eth od
1. Use th e cogn itiv e m aps you h a v e d ev elo p ed (see c h a p te r 3) b u t
m ake th em longitudinal. Pick o u t each th o u g h t a n d trace its ori­
gins— h ow it has transform ed into o th e r beliefs, and h ow its rep re­
se n ta tio n has ch an ged during different stages o f th e client's life.
2. W h at o th e r thoughts, em otio n s, b eh av io rs, o r e n v ir o n m e n ta l trig­
gers have b e c o m e linked w ith the th e m e as it has d evelo p ed ? How
h av e th e m isp erception s spread from o n e z o n e o f a client's life to
another?
5. Have y o u r clients im ag in e w h a t th eir life w ould h av e b e e n like if
th ey had perceived differently. Ask th em to im a g in e h ow th e y
would h av e acted if th ey hadn't had this distorted life them e.

E x a m p le : The Story o f M ary

The m ost pow erful ex a m p le I c a n th in k o f was th e life t h e m e o f a
client I will call Mary.
W h e n M ary was y o u n g sh e w as different from o th e r girls. S h e was
interested in stu dyin g p h ilo so p h y w h ile o th e r girls played w ith Barbie
dolls. H er grad es in sc h o o l w ere not g oo d , a n d a lth o u g h h e r teachers
th o u g h t s h e had potential, shfc kept an sw erin g q u estio n s in odd ways
Historical Resynthesis 285
/

that th e tea ch ers ju d g ed as ab errant. H er friends o f ch o ice w e re older

p e o p le until h e r parents pressed h e r to asso ciate w ith p eople closer to
h e r o w n age.
M ar)' didn't th in k like m ost people. Sh e tried to explain w h y she
b elie v ed certain things o r w h y she th o u g h t so differently, b u t n o b o d y
really u n d e rs to o d w h at sh e m ean t; sh e c o n clu d ed that sh e was too
vapid to ex p la in things well. M ost o f the o th e r girls rejected her and
se em e d em b arra ssed to b e seen with her, so sh e spent m u ch o f h er
early life alone. Her parents w orried and sent her to therapists w h o
n ev er fou n d a n y th in g specifically w ro n g with her. Sh e ju st didn't seem
to fit in w ith her peers.
M a ry was q u ite y o u n g w'hen s h e realized that she w'as b ein g
rejected. Sh e was su re it was b e c a u s e s h e was b ird -b ra in ed . Sh e did­
n't u n d erstan d w h y others thou ght the w ay they did, a n d sh e hadn't
m et a n y o n e w h o th ou g h t her way, so she con clu d ed that she was a
real idiot. S o m etim e s sh e th o u g h t sh e m ight b e crazy, b u t she had
read th e DSM m an u als, a n d knew that sh e didn't sh ow th e sufficient
n u m b e r o f sym ptom s. S h e finally develo p ed th e life th em e that she
m u st b e retarded in so m e way and th at o th er p eople w ere simply
smarter. This was th e o n ly ex p la n a tio n sh e could c o m e up with.
S h e acted o u t this t h e m e th ro u g h o u t m u ch o f h e r early life. She
didn't attend c o lleg e b e c a u s e s h e felt that college was o n ly for bright
p e o p le and sh e didn't w a n t to em barrass herself. Her fam ily didn't
press her. T h ey pushed college on h e r brothers, but believed that girls
o n ly w ent to college to m eet hu sb an d s, a n d since she preferred read­
ing p h ilo so p h y to m e etin g boys, they saw n o reaso n to spend their
m oney. S h e to o k odd jo b s that b o red her v ery quickly, so sh e kept
lo o k in g for others that m ig h t b e m o re interesting. Sh e never found
o n e s h e liked, and c o n clu d ed that sh e was too dull-w itted to e n jo y the
work. S h e o cca sio n a lly to o k so m e adult ed u cation classes at th e local
university, b u t received o n ly average grades— sh e didn't seem a b le to
give th e answ ers the professors w an ted; sh e answ ered essay q u estions
in div ergent ways.
Her relationships w ith m en followed a sim ilar pattern. She d id n t
act like o th e r w o m en ; sh e didn't try to flatter m e n or b o o st th eir egos
or w ear sed u ctive clothing. M ost o f the time she just w an ted to talk,
to find o u t w h a t th ey th o u g h t a b o u t things. M ost m en just tried to get
h e r in to bed, and w h en sh e w ould n't play th e sedu ction g a m e they
th o u g h t s h e was strange, so th ey usually left her for so m e o n e m ore
traditionally fem inine. M ary c o n clu d ed that sh e was to o la m e -b ra in e d
to attract m en.
286. T he N ew Ha n d bo o k of C o g n it iv e ..T h e r a p y T e c h n i q u e s

Because o f all th ese exp eriences, M a ry d ev elo p ed a co re life th em e

about herself. It b e c a m e her overriding philosophy, th e glasses
through w h ich sh e perceived th e world. At the b a se o f this p h ilo s o ­
p h y was o n e sim p le truth: "I am stupid." Since sh e co n clu d e d this over
m a n y years, h e r b e lie f to o k o n th e stren g th o f a religious dogm a.
As sh e got old er things didn't get a n y b e tte r for Mar)'. S h e n ev er
finished college. "Too harebrained," s h e t h o u g h t to herself, b u t sh e
con tin u ed to enroll in n on cred it courses as a n o n d e g re e student. Sh e
w ould sn e a k into g ra d u a te -sc h o o l lectures o n p h ilo so p h y w h en she
could. S h e would h a n g a ro u n d w ith th e stu d en ts after an d try to o p e n
a con versation , b u t s h e fou n d that m ost stu dents w ere n ot interested
in discussing w hat had b e e n covered in class; th ey o n ly w ere c o n ­
cerned w ith w h a t grad e th ey w o u ld receive o n th e next test. T h o se few
th at would talk a b o u t the su b ject w-ould ign o re M a ry w h en th ey dis­
covered sh e w asn 't a real stu dent and h ad n 't ev en ea rn ed an u n d e r­
g rad u ate degree.
M a ry b e c a m e m o re depressed a b o u t life and finally c a m e to se e me.
S h e told m e a b o u t h e r life and her problem s. M o st o f w h a t sh e
show ed m e w'as how very sad sh e was b e c a u s e s h e was su ch a p u d ­
ding head. I asked h e r so m e q u estio n s and en co u ra g ed h e r to express
w h a t sh e had read an d w'hat s h e had b e e n th in k in g ab ou t.
I realized qu ite qu ickly that h e r life t h e m e w as tru ly distorted, and
I tried various rationalistic cogn itiv e te c h n iq u e s to help her, b u t she
rejected them all. Clients hold o n to life th em es despite o v e rw h e lm in g
ev id en ce to the contrary.
Finally, out o f frustration m o r e th a n a n y th in g else, I decid ed on
a n o th e r tactic. I knew that it was risky, b u t if m y gu ess a b o u t M ar)'
was correct, it m ight work. I decid ed to give M a ry a h o m e w o r k assign­
ment, and I g o t her to prom ise that sh e w ould d o it.
I told h e r that a w o rld -fa m o u s w o m a n professor was c o m in g to
tow n an d g o in g to offer a serious lecture on s o m e m atters o f p h ilo so ­
phy (I have disguised th e actu al discipline) in an area that interested
her. Sh e recognized the w o m a n 's w o rk an d agreed that th e professor
w as brilliant. T h e lectures w ere by invitation only, a n d o n ly local u n i­
versity professors and advanced d o cto rate stu dents w e re allow ed to
attend, bill I h a d a friend w h o was a professor o f p h ilo so p h y w h o
could get h e r a ticket. M ar)' was grateful.
T hen I added that th ere w as a catch. I said t h a t after lectu res the
professor usually co n d u cte d a q u estio n a n d a n sw e r period for the
audience. During this tim e, no m atter h o w n e rv o u s s h e was, s h e m u st
ask the best q u e stio n sh e coilld. In addition and m ost im p o rtantly, I
Historical Resynthesis 287
/

w an te d h e r to do so m eth in g else. After th e lectures th e professor

w ould o ften m eet w ith so m e o f th e p ro m in en t local professors and
ad v an ced g rad u ate stu dents an d invite th em to her hotel, w h ere they
w o u ld discuss p h ilo so p h ica l matters. I told M ary that sh e m u st do
ev e ry th in g sh e could to b e part o f that group. "Be as assertive as you
m u st b u t jo in th e group."
S h e stren u o u sly ob jected . S h e said sh e could n't d o it. How could
sh e talk to this fam o u s w o m a n w h o se w ork sh e had ad m ired for
years? Sh e w ould b e su rro u n d ed b y professors and sh e hadn't even
finished college. 1 rem in d ed h e r o f h er promise, and finally and very
relu cta n tly s h e agreed.
I th e n en d ed th e sessions an d told M ary w e would stop further
co u n s e lin g u n til after th e lecture. Sh e prom ised to call and tell what
had happ ened .
A b o u t a m o n th later sh e p h on ed an d told m e sh e had g o n e to the
lecture and sat in the back. T he place was crowded with professor
typ es a n d grad u ate students. Sh e recognized so m e o f the professors,
m a n y o f w h o m h a d w ritten b o o k s an d articles. T h e graduate students
w ere s o m e o f th e p eople sh e had seen w h en sh e audited th e classes—
th e y had b e e n the m ost v erbal and con fid en t students.
S h e said th a t (he lecture had b e e n wonderful, and th a t during the
q u e stio n period afterw ards sh e had b e e n very nervous w h ile waiting
for a c h a n c e to ask her qu estion. T h e professor answ ered m ost o f the
q u estio n s qu ickly a n d concisely. M ary asked her question, w hich was
based u p o n an aspect o f the professor's th e o ry that sh e had thou ght
a b o u t b u t h a d n 't b e e n ab le to figure out. T h e professor looked at her
an d smiled, th en a n sw ered th e qu estion in great detail, goin g on for
at least tw e n ty m inutes. T h e answ er was brilliant, and M ary listened
in ten tly to ev e ry th in g th e professor said.
After the talk, M ar)' ap p ro ach ed the stage to see the professor, w ho
was talkin g w ith colleagues. M ar)' tried to n u dge in but a professor
b lo ck e d her. He told h er so m eth in g like, "Dr. ---------- is very busy,
y o u n g lady. Sh e has a very tight schedule, is tired from h er long flight
a n d really needs to get a w a y So, w e w o u ld appreciate it if you would
leave." But M ar)' had insisted a n d finally had th e o p p o rtu n ity to say
hello. T h e professor recognized h er and said, "Oh. You are the you ng
lady w h o asked that ex cellen t qu estion, h ow can I help you?" M ary
ask ed w h e th e r sh e co u ld jo in the g ro u p o f colleagues so that she
c o u ld listen and learn m o re a b o u t the theories. Sh e had alm ost
begged. Sh e prom ised n o t to b e a b o th e r — s h e ju st w an ted to sit in the
b a c k and listen. O n e o f th e c o n fe re n ce organizers overheard th e c o n ­
288
T h e N ew H a n d bo o k o i- C o g n i t iv e T h e r a p y T e c h n iq u e s

v ersation a n d said that th ere w ere alread y to o m a n y people, b u t the

professor said, "O h let h e r com e, George. O n e m o r e w o n 't m a k e a n y
difference."
M a ry w en t to th e hotel suite a lo n g with a b o u t 10 u n iversity p ro ­
fessors and g rad u ate students. T h ey all had coffee and d o u g h n u ts and
talked a b o u t th e professor's theories. Initially M a ry didn't say m uch,
b u t grad ually sh e started to ask q u estio n s and th en b eg a n to give
voice to s o m e o f h e r ow n ideas. It got later a n d later an d th e o th e r
p eople started to m a k e th eir ap olog ies and leave. Finally th e professor
and M a ry w ere left there alone. T h ey talked until five o 'clo ck in the
m orning, discussing vast, sw eep in g concepts. T h ey used yellow pads
to illustrate th eir points. T hey d ran k 10 cups o f coffee. M a r y said, "It
w as w onderful— th e b est th in g th at h ad e v e r h a p p e n e d in m y life."
Right b efo re th e professor left sh e had asked M a r y w h ic h g ra d u a te
sch o o l sh e w as attending. At this point M ary had b e c o m e com fortab le,
so sh e decided to tell the truth. Sh e told th e professor that sh e w as not
in grad u ate sch ool and that sh e h ad n 't ev en finished h e r u n d erg ra d ­
u a te degree. This astou n d ed th e professor, b u t sh e g a v e M a ry her
h o m e p h o n e n u m b e r and suggested that sh e call in a co u p le o f weeks.
T he professor hinted that s h e m ig h t b e a b le to h elp Mary.
This to o k p lace m a n y years ago, and a lot has h a p p e n e d sin c e then.
The professor h elp ed M a ry c o m p le te h e r u n d erg ra d u ate d egree v ery
q u ickly by directing h e r to a college w h e r e s h e could pass classes by
challen g in g th e courses. Sh e w ould take th e final e x a m s a n d if she
answ ered th e q u estio n s satisfactorily, sh e was giv en credit for the
class. Later the professor g o t h er into a g o o d g ra d u a te sc h o o l and
h elp ed h e r receive an assistantship so that s h e could afford to attend.
M ary has d o n e v ery well. S h e co m p leted h e r Ph.D. in record time,
p u b lish ed m a n y articles for professional journals, and ev en w ro te a
b o o k . Her m ost recent w o rk was review ed as s o m e o f th e m ost in n o ­
v ative in the field. For th e first tim e in her life, M a n ' is c o n te n t and
happy.
B ecau se o f a series o f early critical events, M a r y h a d c o m e to an
in cred ib ly e rro n e o u s co n clu sio n a b o u t herself. Sh e'd n o ticed early
th a t s h e was different fro m others, an d h a d co n clu d e d (as m a n y chil­
dren do) that this difference m e a n t th a t s h e w as in ferior in s o m e way.
Her peers and teachers treated h e r this way, so sh e b elie v ed it h e r s e lf
In reality, th e reason th a t M a r y w as so different w as th a t s h e w as a
genius—-o n e o f th e se rare p e o p le th a t co m es a lo n g o n ly occasionally.
Sh e could see th in gs in a clearer a n d m o r e c o m p r e h e n siv e w a y th a n
th e vast m a jo r ity o f us, b u t w fiile s h e w a s b rillia n t a b o u t m o st things,
Historical Resynthesis 289
/

sh e cou ld n 't read h erself at all. It m a y sou n d strange for so m e o n e to

b e so aw are in so m e areas b u t totally b lin d in others, b u t this is often
true o f geniuses, an d it was true o f Mary.
M o st p e o p le m eetin g M ar)' didn't reco g n ize her ability b ec a u se it
ta k e s talent to recognize genius. It takes excellent skill to recognize
s u p rem e skill. It takes a Haydn to recognize a Mozart. T h e professor
w'ho m e t M ar)' had th e k n ow led ge an d u nd erstan d in g to recognize
t h e ex ten t o f M ary's ability.

C om m en t
The w ay I tried to h elp M ary c h a n g e h e r life th em e was u n o rth o ­
dox. It w as lu ck that the professor sh ow ed up at the right time. Life
th e m e s are th e m ost pow erful cogn ition s clients can have, an d they
will strongly defend them , dam agin g as they m ay be. W e therapists
nee d to use all o f o u r skills and ju d g m en ts to put a dent in them . Usu­
ally th e y are so well defend ed that rational a rg u m en ta tio n will not
work. O u r b e st c h a n c e o f helping o u r clients is to try to give them the
right kind o f e x p e rie n c e so that they will discover the truth for th em ­
selves. By u sin g th e e n v ir o n m e n t w e facilitate clients' ability to prove
to th em selv e s w h e th e r th eir life th e m e s are true. If you can arrange
su ch a test for y o u r clients you are fortunate.

F u rther In fo r m a tio n
T h e im p o rta n c e o f m od ifying a client's life them es has increased in
recent years. Today, cogn itive restructuring therapists spend m ore time
w o rk in g o n clients' life th e m e s th a n o n present cognitions.
S c h e m a -fo c u se d therapy has developed a similar system o f m odify­
ing life th em es that includes a life review and experiential, interper­
sonal, a n d b eh av io ral tech n iqu es (M cG inn & Young, 1996, pp. 196-200).

R es y n t h esiz in g E a r ly R ec o llec t io n s

Principles

An im p o rta n t principle in psychology is k n ow n as th e rule o f primacy.

It m e a n s th at clients pay m o re a tten tio n to th eir first im pressions than
to th eir later ones.
M a n y th erap ies attrib u te great significance to a client's first m e m ­
ory. For ex am p le, Adler (1964), Bind er and Sm o k ie r (1980), Bruhn
290 T he N ew H an d bo o k of C o g n i t iv e T h era py T e c h n iq u e s

(1990b), Edwards (1990), L a s t ' (1997), M o s a k (1958,1969), an d O lson

(1979) em ployed clients' earliest recollection s as an im p o rta n t ingredi­
ent in th eir therapies.
C ognitive restructuring uses a client's earliest m e m o rie s to identify
core beliefs, b u t w ith ou t a p sy ch o d y n a m ic th eoretical fram ew ork. Fre­
quently, (he earliest m e m o r y identifies o n e o f a client's lifelong beliefs.
This b e lie f p ro b a b ly didn't origin ate with th e event, as usu ally o n ly a
w h o le series o f e x p e rie n ces can d o that, b u t the earliest ev en t often
unveils the ex isten ce o f the b e lie f du ring an early stage o f a client's
life.
M a n y m istaken beliefs that cau se clients pain are rooted in th ese
early personal histories. The dam agin g p ercep tion s m ig h t h av e b e e n
im p lan ted long b efo re a clien t could process in fo rm a tio n in a rational
m anner, and du ring the years since th at time, a n en tire pattern o f
thinkin g m ight h av e evolved based u p o n that m istak en begin n in g. A
pattern o f b elie v in g can b e altered if th e original m istak en b e li e f has
b e e n discovered and replaced.

M eth o d 1. I m a g e Exercise
1. Have clients im ag in e a c u rre n t situation w h e r e stro n g e m o tio n
occurs. Take so m e tim e o n this. Help clients to use all th eir senses
to m a k e th e scen e vivid. W h e n th e scen e is clear, ask th e m to focus
on the co re belief, gestalt, or them e.
2. Instruct y o u r clients to focus o n the first or earliest recollection they
have o f th in k in g a belief. C o n cen trate o n the initial situ ation w h en
the em o tio n developed. Have them im a g in e th e sc e n e again and
visualize it clearly. It is helpful if y o u r clients say the false b e l ie f to
them selves in a child o r ad olescen t voice.
3. For d am agin g beliefs, ask clients, "W h at w as e rro n e o u s in y o u r
interpretation o f this event? How did you m isp erceive it? W h a t did
you say to y o u rse lf that was u n tru e? W h y was y o u r in terp re ta tio n
m istak en ? W h o or w hat ex p erien ces ta u g h t you this m isp e r c e p -

4. Discuss with y o u r clients that th ey are m isju d g in g th e p re sen t situ­

ation m th e sam e way that th e y m isju dged th e earlier o n e
5. Correct th e earliest m ista k en belief. H ave clients im ag in e redoing
the situation b y th in k in g a useful, realistic th o u g h t instead o f w hat
was first believed. Ask th e m to im a g in e h ow th e y w ould h av e felt
and h ow th ey would h av e acted differently i f th e y had th o u g h t d if-
ferently. * ”
Historical Resynthesis 291
/

6. Finally, get y o u r clients to picture th eir present difficulty differently.

C orrect th e present m istak en b e lie f ju st as th e earlier o n e was co r­
rected.

E x a m p le 1
T h e rule o f prim acy hold s true for m a n y o f clients' earliest ex p eri­
ences. O n e im p o rta n t e x p e rie n ce is a client's first mentor. Clients' first
teach ers w h o tau g h t th em s o m e m eaningful principle o f life are
alw ays special. T h ey m ay have learned from m a n y o th er teachers
sin c e then, b u t th ere is a hallow ed place in their m e m o ry for their first.
Clients' first attitudes also hold primacy. Santa Claus, th e Easter
b u n n y , a n d th e to o th fairy m ay seem absurd, b u t th ey feel w arm and
close inside. First religious beliefs seem like th e o n ly true religion.
T h o u g h th e client m ay lon g sin ce have b e c o m e agnostic or rejected
the old theology, in tim es o f con fu sion th ey feel draw n b a ck to their
earlier faith.
A first ac h ie v e m e n t o r acco m p lish m e n t is a n o th e r im portan t ex p e­
rience. T he tim e they w o n th e rib b o n fo r th e th ree-legg ed race or
scored the w in n in g b a sk et will take p reced en ce o v er later, m u ch
greater accom p lish m en ts.
T h e first tim e they travel to a n ew and distant cultu re will often
m a k e this cu ltu re a n d these p eople forever special to them . O n e o f my
clients re m e m b e rs h er first trip to So u th America, du ring w h ich she
flew from M iam i to Lima, Peru. T he flight seem ed to take forever, but
w h e n s h e arrived a n d w alked arou n d the large city square, she was
e n c h a n te d w ith th e str a n g e -lo o k in g p eople w earing m ulticolored cos­
tu m es and th e u n u su a lly sh ap ed buildings, so m e o f w hich dated back
to th e con q u istad ors. Sin ce that tim e, w h e n e v e r sh e sees pictures o f
Lima o r reads an article a b o u t Peru, s h e feel strangely invigorated and
excited. Even her later kn ow led ge that Peru is a very p o o r country
w ith m u ltiple social and political p rob lem s doesn't d a m p en her
en thu siasm .
The first h o u se that clients ev er lived in m ay forever d efine w hat a
h o u se sh o u ld be. A m a n w h o grew up in a th re e -sto ry h ou se m ad e o f
s to n e n e v e r feels q u ite co m fo rta b le in brick hou ses or ran ch -sty le
w o o d e n structures. M a n y p e o p le search desperately in W y o m in g for
co lo n ia l-sty led h o u se s o r lo o k fo r a d o b e h acien d as in M aine. S o m e
A u stralian clients qu ietly yearn for a h o u se like o n e n e a r the M u rray
river w ith g u m trees, a v eran d ah o u t the front, a n d kan g aroos out the
back. If they are search in g ou tsid e Australia, their h o p e is forlorn. But
292 T he N ew H a n d bo o k oe C o g n i t iv e T h e r a p y . T e c h n iq u e s

for th em and for m ost clients th eir first h ou ses are th e o n ly real
hou ses; a n y th in g else is con sid ered a n inferior substitute.
Similarly, clients' ideals o f w h at a fam ily is like often reflects the
w ay their family was. T he true definition o f a m an is o ften th eir father,
th e definition o f a w o m a n is their mother. A real m a rria g e is w h at
their parents had with each o th e r even if it was defective.
They often co n sid er a su b stantial jo b as th e first o n e th a t g a v e th em
solid satisfaction. T hey m ay view o th e r en d ea v o rs th at are m o re prof­
itable as m erely lucrative hob b ies.
Finally, th e definition o f true love is o ften based o n th e client's ear­
liest rom ance, despite its having b e e n sh o rt-liv ed o r a p o o r match.
T hey hold it in a special p lace in th eir m e m o r y that later, m o re im p o r­
tant relationsh ips don 't assail.
T h ese early e x p e rie n ces take o n so m u ch im p o rta n c e b e c a u s e they
are fresh and new. Clients e n te r th em with few fram ew ork s to gu ide
them, so th eir first e x p e rie n c e b e c o m e s their first prototype, th e m o d e l
b y w h ich they ju d g e all that c o m e s later. W h e n their early ex p erien ces
are positive th ey give them a g en tle reference point, a soft rem in d er
o f a safe place inside.

E x a m p le 2 : The Story o f R en ee
U n fo rtu n ately the rule o f prim acy has a n eg ativ e side. If early e x p e ­
riences are positive, they m ay serve as g o o d m od els for later life. But
w h en negative, they m a y ca u se lifelong m istakes in thinking. Early
distorted learnin g m ay harden th eir p ercep tion s into c o n c r e te th at a
lifetim e o f later ex p erien ces can't crack.
O n e client's story reveals h o w this happens.
Several years ago R enee relu ctan tly c a m e to see me. He w as from
France and his c o m p a n y had recen tly transferred h im to th e United
States. He was havin g a terrible tim e; h e felt deeply hom esick, c o u ld ­
n't find a n y fellow Fren ch m en to talk to, and sp en t his ev en in g s and
w eek end s a lo n e staring at the TV. His isolation w as ca u sin g a d eep
depression, and h e needed to get o u t o f th e h o u se an d start m eeting
people. I arranged a series o f activities, carefu lly p la n n ed so that he
could grad ually develop so m e friendships in th e U.S.
W h e n th e plan was presented to him h e lo o k ed a n n o y e d an d asked
ju st o n e qu estion, "Will th ere b e a lot o f Yanks there?"
Taken aback, I said, "Well . . . er . . . yes. W e are in th e U nited States
and this c o u n try has a te n d e n c y to b e o v erru n w ith Yanks."
"Then," h e said, "I w o n 't go."
A curiou s an sw er since he was n ow living in th e U nited States, so
Historical Resynthesis 293
/

w e exp lored w h y h e felt this w ay ab o u t Am ericans. It turned o u t that

his first e x p e rie n c e with A m ericans had b e e n very negative.
R en ee grew up in a small tow n in th e sou th o f France; it was fairly
isolated and fa r from th e usual tourist routes. He had heard Am erican
m u sic and seen A m erican m ov ies and TV shows, b u t h e had never
actu ally m e t an Am erican.
O n e day h e w e n t to tow n with his fath er and saw a very fat m an
stan d in g in th e local hotel. T he m a n w as dressed in green baggy shorts
a n d was w ea rin g an o ra n g e shirt with prints o f little yellow fishes all
o v e r it. He was sh ou tin g at a clerk b e h in d th e desk. He was apparently
c o m p la in in g a b o u t the ro o m n ot having a color television and was
d e m a n d in g th a t th e clerk find him o n e immediately. He yelled that
France had th e worst service h e had ev er seen, and that this kind o f
th in g w o u ld n 't b e tolerated b a c k hom e. W h ile h e was b ro w b eatin g the
clerk, his tw o pudgy children w ere ru n n in g up an d dow n the lobby
pulling leaves o ff o f the potted plants and clim b ing over the furniture
w h ile his o b e s e wife look ed o n w ith a b o red expression. Renee's father
turned to h im an d said, "Those are Americans!"
R enee n ev er forgot this first im pression. It colored all o f his su b se­
q u e n t contacts. W h e n h e saw o th e r A m erican tourists h e rem em b ered
o n ly th o se w h o lo o k ed and acted like th e m a n in the lobby. Those
w h o didn't, h e assum ed, w ere from C anada o r so m e o th er place.
His selective p ercep tion picked out o n ly th o se A m ericans w h o were
egotistical, fat, noisy, and w h o sp en t their vacations insulting his
country. As a result h e learned to feel a rep u g n a n ce for a n y o n e and
e v ery th in g A m erican. W h e n his b o ss told him he had to w ork in the
U.S., h e had a d a m a n tly refused, but to keep from b e in g fired h e had
relu ctan tly agreed.
The rule o f prim acy was explained to Renee, but he w asn't c o n ­
v inced . He still felt m ost A m erican s w ere o f th e loud, arrogant, and
ugly variety. To ch allen g e him I suggested that h e g o to so m e places
and c o n d u ct a survey. "Even if y ou don 't like the A m ericans there, at
least c o m p le te th e study. D e te rm in e h ow m a n y are like the m a n in the
lobby, and h ow m a n y aren't."
A few m o n th s later h e c a m e b a ck w ith the results. He had found
s o m e ugly Am ericans, b u t m ost o f th e tim e he'd m et p eople v ery sim ­
ilar to his French friends b a ck h om e. M o r e surprisingly, he'd b e c a m e
c lo se to a few A m erican s and sp en t so m e o f his free tim e goin g to
b aseb all g a m e s a n d parties w ith them. His loneliness was g o n e and his
d ep ressio n h ad lifted.
I said, "See? You w ere overgeneralizing a b o u t Americans." His
resp o n se surprised me.
294 T h e N ew H a n d b o o k of C o g n it iv e T h e r a p y T e c h n iq u e s

"No I wasn't!" h e said. "I've ju st m e t those few Yanks w h o a re the

exception."
His p reju d ice co n tin u e d and p ro b a b ly rem a in s to this day. It show s
that a n y o n e can hold o n to their first im p ression d espite stro n g e v i­
d e n ce to th e contrary. But he had m e t so m e friends an d didn't need
m y help a n y m o re, so w e finished o u r therapy.
O n leaving h e said, "You kn ow for a Yank, y o u 're okay." M a y b e from
his vantage p oin t this was a great com p lim en t, b u t I'm not so sure.

M ethod 2. Resynthesis Worksheet

T he follow ing w o rk sh eet m ay b e used in th e resyn thesis process.

Resynthesis Worksheet
Present Situation_________________________________________________________
Emotional Response______________________________________________________
Present Belief ab ou t Present Situation

Early Recollection___________
(preformal situational events)
Emotional Response_________
Mistaken Early Belief________
Corrected Early Belief_______
Corrected Present Belief

1. Use th e client's m aster list o f beliefs a n d h av e clients c o n n e c t the

beliefs to th e situ atio n s in w h ich th ey occurred. Each o f th ese situ­
ations shou ld b e listed u n d er "Present Situ ation" o n the w orksheet.
T h e beliefs associated with e a c h situ atio n sh ou ld b e listed u n d e r
"Present B elief'
2. Look for critical ex p erien ces th e client had prior to or d u rin g early
adolescence. First, identify th e events. For v ery early ev ents y o u r
clients m ay b e a b le to recall o n ly v a g u e im ages, b u t ev en if th ey are
on ly fragm ents o f senses and im p ression s h av e y o u r clients v isu al­
ize th em as clearly as possible. Record them o n th e w orksheet.
3. Form ulate into a se n te n ce th e m ista k en b e lie f that resulted from
each o f th ese events. Record th o se se n te n c e s o n the w orksheet.
4. After careful discussion w ith y o u r client, correct each early thou gh t.
Record that in form ation o n th e w orksheet. T he ea rlier m istak en
Historical Resynthesis 295
/

in terpretation sh ou ld b e ex p u n g e d b y h aving y o u r client discover

t h e correct in terp retation o f the early events. Replace all early mis­
taken co g n itio n s co n n ec ted to th e events.
5. O n c e th e m istak en early irrationalities have b e e n corrected, help
th e client to c h a n g e present irrational thinking.
6. H ave y o u r clients regularly use th e w ork sheet— finding m istaken
beliefs, identifying th eir early origins, correcting the earlier misin­
terpretations, a n d then ad op ting a m o re functional b e lie f as a guide
to th eir present lives.

E x a m p le 1
Present situation: Client got an xiou s at party that m a n y international
stu dents attended.
Present belief: People from o th e r countries are dangerous.
Early situational event: Client was isolated from a n y b o d y n ot in the
im m e d ia te fam ily; was overprotected and not exposed to u nusual
en v ir o n m e n ta l stimuli. Sh e h a d never seen a n y o n e w’ho look ed "dif­
ferent."
M istaken early interpretation: A n y th in g n ew or novel is dangerous.
Corrected early interpretation: T h e n ew an d novel can b e exciting and give
m e an o p p o rtu n ity to grow a n d expand. T he new is no m ore danger­
ou s th a n th e k n o w n and familiar.
Corrected present belief: It is interesting to m eet p eople from o th e r c o u n ­
tries; I h a v e an o p p o rtu n ity to learn m ore a b o u t o th e r cultures.

E x a m p le 2
Present situation: Client was so afraid o f b e in g a lo n e in the ev en in g that
s h e su rro u n d ed h e r s e lf w ith as m a n y friends as possible so that she
w ould alw ays h av e s o m e o n e to invite over.
Present belief: I am a v ery so c ia b le person.
Early situational event: Sh e had b e e n a b a n d o n e d b y a parent w h en young.
M istaken early interpretation: I will n e v e r allow m y self to b e a b a n d o n e d
again.
Corrected early interpretation: I am not a child a n y m o r e a n d I don 't need a
person 's p rotection like I o n c e did. I can survive alone, and don 't need
to b e terrified a b o u t b e in g b y myself.
Corrected present belief: I no longer need to su rroun d m y self with 50
friends in o rd e r to protect m y self from ru n n in g o u t o f people. I can
pick a few close friends w h o really m e a n so m eth in g to me.
296 T h e M ew Han d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

E x a m p le 3 '■
Present situation: Client would n ev er u n d erta k e a n y task requ irin g
patience, co n ce n tra tio n , a n d persistence.
Present belief: R outine is boring.
Early situational event: As a child the client en g aged in ex ten siv e day­
dream s to m a k e up for a socially im p o verished early ch ild h ood .
M istaken early interpretation: T h e o n ly w ay to en rich o n e 's life is th rou g h
fantasy and im ag ination. Everyday activities are dull, drab, and gray.
Corrected early interpretation: Real life is at tim es d ra b a n d gray and at
o th er tim es b rig h t a n d colorful. Actual life is far m o re m e an in g fu l th a n
fictional fantasies. True satisfaction can o n ly c o m e from en g a g in g in
th e struggles, trium phs, and tragedies o f real life, not b y livin g in a
fairy tale world o f m agic w h ere fate co n tro ls all successes. M e a n in g
co m es from h u m a n b ein g s striving against all odd s to m a k e things
better, not from escaping into sa n g u in e fantasies.
Corrected present belief: C o n cen tratio n a n d p ersistence o n variou s activ i­
ties provide the fou nd ation for m ak in g m y life u ltim ately m ean in gfu l
and enriching.

C om m en t
The em o tio n al c o m p o n e n ts o f clients' first e x p e rie n ces are usu ally
very strong. It is therefore im p o rta n t to search m e m o ries slowly. Have
y o u r clients im ag in e o th e r early positive e x p e rie n ces to offset p ow er­
ful negative feelings that may em erge.
The h yp oth esis b e h in d this te c h n iq u e finds su p p o rt in th e w o rk o f
such n o ted theorists as Piaget (1954). He argued th at th o u g h ts, them es,
an d beliefs accepted in to the frontal lo b e d u rin g the p reop eration al
stage o f brain d e v elo p m en t (ages 2 - 7 ) are likely to b e b a sed u p on
m a n y kinds o f logical errors. D uring the c o n c r e te o p e ra tio n a l stage
(ages 7-11), th e individual c a n n o t abstract reality in term s o f "as if"
thinking, v iew in g p rob lem s c o n c r e te ly A ny m isp ercep tion s th at
accru e du rin g these tw o stages o f intellectu al d e v e lo p m e n t will b e
stored in lo n g -te rm m e m o ry / an d will not b e easily rem ov ed as th e
individual m atures.
A ssum ing that this h yp oth esis is correct, it se em s clea r th a t early
m istaken beliefs that were sy n th esized into clients' overall p a ttern s o f
th ou g h t m u st b e su b seq u e n tly resyn th esized i f clients are to g a in a
h ea lth ie r perspective o n th em selv es an d th e w orld a r o u n d them .
W h e n d o n e correctly, this te c h n iq u e can provide rapid, d ram atic
 Historical Resynthesis
297
/

shifts in clients' perceptions. P sych od yn am ic therapists often use ele­

m e n ts o f this a p p roach in th eir th era p e u tic practice. The cognitive
restru ctu rin g a p p ro a ch differs b o th theoretically and in practice. This
is b e c a u s e o f th e e m p h a sis it places u p o n actively correcting th e faulty
life t h e m e and b e c a u s e o f its reliance u p on the hyp oth esis that pre-
o p e r a tio n a l and c o n cre te beliefs are read ily accessible to conscious
m an ip u lation . In o u r view th e b attle doesn't rage b e tw e e n th e c o n ­
scious a n d u n con scio u s, o r a m o n g repressed conflicts o f the ego,
su perego, an d id; rather, th e co n flict is b etw een w h at is verifiably real
and w h at was o n c e spu riou sly learned.

F u rther In fo r m a tio n
A very early e x a m p le o f u sing a client's earliest ex p erien ce is Freud's
fa m o u s case o f K ath arin a (Breuer & Freud, 1937; Freud, 1933). His
tr e a tm e n t o f h e r a n x iety sy m p to m s (w hich revealed th em selves in
b re a th in g difficulties) was straight cognitive therapy. Although he
w ould later d ev elo p his p sy ch o d y n a m ic theory, initially his treatm ent
o f this client w as very sim ilar to o u r cognitive resynthesis technique.
His co u n selin g leads w ere as follows.
Freud:

• "W h at are y ou co m p lain in g of?"

• "Describe to m e h o w su ch a state o f 'difficulty in breathing' feels."
• " W h e n you h av e the attack, d o y ou always th in k o f the sam e thing?"
• "W h en did y ou first get them (anxiety attacks)?"
Fraulien K ath arina, if you could n ow recall w h at w ent through
y o u r m in d at th e time that y o u got the first attack, w h at you
th o u g h t at that time, it w ould help you."

K ath arin a recalled a sc e n e w h ere h e r u n cle was m ak in g love to her

cou sin and s h e felt disgusted.
Freud then restructured this scen e b y saying that sh e was n ow a
g r o w n -u p girl, k n e w all a b o u t th ese m atters (sexual facts o f life) and
could n o w u n d erstan d what was g o in g on. K alherina answ ered, "Yes,
now, certainly." T he a n x iety attacks ceased from this point o n (Breuer
& Freud, 1937).
Piaget's works a re ex ten siv e (see Piaget, 1954, 1963, 1970, 1973, 1995;
M o n ta n g e r o & M au rice-N aville, 1997).
For a discu ssion o f early preform al recollections and their im p o r­
tance, se e M o sa k (1958, 1969). His research review d em on strates that
preform al recollection s reflect th e b asic client life them es. T h e m ost
298 T h e . N e w H a n d b o o k o f Co g n it iv e T h era py T e c h n iq u e s

c o m p reh en siv e review o f preform al attitudes a n d their use in therapy

is b y Bru h n (1990a, 1990b), Edwards (1990), and O lso n (1979).

R es y n t h esiz in g Fa m ily B e l ie fs

Principles

C ognitive histories b eg in with a client's family. T he fam ily is th e

earliest sou rce fo r a client's beliefs an d a p rim ary so u rc e th ro u g h o u t
m ost o f a client's life. Clients are b rou g h t u p n ot o n ly to act in certain
ways, but also to th in k in certain ways. As children th e y trust that
their parents are th e soul possessors o f truth. Parents seem so pow er­
ful to a sm all child that th ey c o n clu d e th a t m ight}' p ow er is im m e d i­
ately tra n slatab le into m ig h ty truth. W h ile it is factual th at parental
p ow er fades as clients get old er (and w ith it clients' certa in ty o f
parental truth), their m o th e rs' and fathers' beliefs will alw ays hold a
special p lace in their b e lie f systems.
T he fam ily extend s b ey o n d a client's parents and can include
b roth ers and sisters, grand parents, au n ts and uncles, nieces, nep h ew s,
and cousins. All m e m b e rs o f the fam ily m a y hold the s a m e central
belief. T he family th e m e m ay b e, "We are special," or "W e h av e a nasty
little secret." This p h ilosop h y m ay b e as m u c h a fam ily characteristic
as th e family's upturned nose, te n d e n c y towards flat feet, o r red hair.
Clients m ay h av e long since left their fam ily o f origin b u t still c a m '
the attitude the fam ily implanted.
M a n y clients don't see the significance o f their fam ily beliefs b eca u se
they th in k that their o w n attitudes are co n sid era b ly different from
those o f their parents. They are often mistaken. Clients holding o p p o ­
site Bs from their parents m ay still h av e related cognitions. O n e may
cause th e other. For exam ple, a family m a y have believed that social
a p p earan ces are im portant. T h ey m ay have instructed their so n c o n ­
stantly ab out shining his shoes, w earing the right clothes, h aving his
h a ir cut, cleaning his fingernails, etc. T he son m ay b e lie v e the opposite.
As so o n as h e left h o m e h e m ay have throw n aw ay all o f his p a re n t-
b o u g h t clothes and replaced th em with grunge, let his h a ir g o ratty and
long, not cleaned his fingernails. He m a y h av e th o u g h t th a t h e was
clear o f his family's influence, b u t h e w o u ld b e w rong. W h e th e r he
b elieves exactly as his family or exactly the opposite, the c o m m o n ele­
m ent is that h e is still reacting to his family. M en tally his fam ily is still
directing his choice o f clothes. W h e th e r w e place a plus o r m in u s sign
next to his beliefs, his parents' cogn ition s still d o m in a te him.
Historical Resynthesis 299

A n o th e r typ e o f b e lie f m a y also illustrate the im p o rta n c e o f family

beliefs. T h ere is a type o f co g n itio n that is n eith er the sam e n o r the
o p p o site ol th e family's th em e. It's a synergistic belief, a b elie f that acts
in c o o p e r a tio n with th e fam ily's and the child's beliefs. Like pieces o f
a jigsaw, th e tw o Bs m ay fit together. Families m ay train their m e m ­
b ers so that all o f the individu al Bs to g e th e r form in a synergistic pat­
tern. It b e c o m e s a fam ily d an ce with e v ery b o d y d o in g a slightly
different step, b u t all steps are sy n ch ron ized with each other. For
exam p le, Father plays the h eav y and does a tan go like— "W hy are kids
so irresp o n sib le today? W h e n I was a kid I didn't h av e a car until I was
25." M o m c o u n te rs with a w'altz, "Leave th e kids alone. All their friends
a re allow ed to use th e car, so w h y can't they?" T h e son does a jive step,
"I'm old en o u g h to o w n m y ow n c a r: And d a u g h te r tries a c h a -c h a by
d a n c in g into h e r b e d r o o m crying, "N o b o d y lets m e d o anythin g
a ro u n d here."

M eth o d
1. M a k e a g rap h o f all the key p eople in y o u r client's family. List their
first n a m e s a n d ages and sh ow the im p o rta n ce o f th eir relationship
to th e client b y using arrows. Be sure to include their parents,
gran d parents, aunts, uncles, or a n y o th e r m e m b e r that had a sig­
nificant in flu en ce o n them.
2. List th e m a jo r beliefs, principles, values, and attitudes held by the
p e o p le o n th e list. Look for beliefs shared b y m ost o f the m em bers.
5. S e c if you can collapse these principles dow n to a few co re beliefs.
4. How did th e fam ily teach each core altitude? How were m e m b ers
rew arded for b elie v in g in th e principles o r pu nished for not b elie v ­
ing in them ?
5. D escrib e h ow y o u r client's fam ily acts differently from o th e r fami­
lies based o n th e family's principles?
6. C o m p a re th e family's beliefs to th e beliefs en u m erated o n your
client's m a ster list o f beliefs. How m a n y o f them are related? Are
th e y collateral— th e sam e, th e opposite, o r synergistic?

E x a m p le
P ro b a b ly th e m ost in lricale fam ily d an ce and th e best ex a m p le o f
a synergistic B is th e a lc o h o lic shuffle. T he w h ole family plays. Dad
leads o ff b y drin king every night. He loses fou r jo b s in a year, gets
picked up for th ree DUIs, and ends up in a d etox unit. T he rest o f the
300 T h e N esc ...Ha n d b o o k o f Co g n it iv e T h f r a p y T e c h n iq u e s

fam ily resp on d s with carefully c h o re o g ra p h e d cou n terstep s. M o m

clean s up Dad's messes, bails him o u t o f jail, and calls his b o ss to say
h e is sick again. D au ghter b la m es M o m for b e in g a rotten wife and
applies for th e jo b herself. T he so n feels ignored and tries to get a tte n ­
tion b y stealing cars a n d scorin g c o c a in e w hile b la m in g M o m a n d Dad
for b e in g such rotten parents.
It's hard for th e therapist to b rea k u p this d an ce b e c a u s e th e part­
ners h av e gotten so g o o d at it. It can b e a m a jo r p ro b le m in treatm ent.
M a n y alcoholics are ab le to stop drinkin g w h e n th ey are aw ay from
th eir families in an inpatien t setting. B u t w h en th ey g o b a c k hom e,
th ey start the d an ce again. B ecau se Dad has stop p ed d rin k in g the
w h o le family gets o u t o f step. M o m has n o o n e to play n u rse for a n y ­
m ore, so sh e feels lost and useless. D au gh ter can't play su b stitu te wife
an ym ore, a n d Son gets stuck w ith a c o ca in e h a b it th a t h e c an 't b la m e
o n a n y o n e but himself. S o m e families b e c o m e so frustrated w ith the
changes th at the w h o le fam ily tries to get Dad d rin k in g again. From
their p oint o f v iew th e d an ce had changed , a n d as b ad as the old o n e
was at least the family was fam iliar w ith th e m u sic and k n e w th e steps.
C onsequently, m a n y fam ilies will su b tly try to get Dad to drink
again b y leaving o p e n e d w h isky b o ttle s a ro u n d the h o u se or by
accu sing Dad o f b e in g w o rse w h en he's s o b e r th a n h e w as drunk.
Everyb od y w an ts to do th e old a lc o h o lic shu ffle again. S o b rie ty had
stop p ed th e dance.

C om m en t
Your client m ay m od el after o n e fam ily m e m b e r ra th e r th a n the
w h o le fa m ily In this instance, c o m p a r e y o u r client's beliefs w ith the
m odel. T h e m od el m a y or m a y n ot b e a parent. T h e key fam ily m e m ­
b e r is the o n e m ost salient and im p o rta n t to y o u r client.

Further In fo r m a tio n
D ysfunctional cognitions in children are produced and m ain tain ed
b y the fam ily system (Alexander, 1988; Kendall, 1991). In terven tion s
with family system problem s h av e b e e n ex tensiv ely discussed. R obert
Taibbi has developed an extensive guided im ag ery exercise th a t r e s y n -
thesizes family beliefs (Taibbi, 1998). Also see th e follow ing articles and
b o o k s for a review o f o th er cognitive tech n iqu es used in fam ily th er­
apy (Bedrosian & Bozicas, 1993; Ellis, 1991; Ellis et al., 1989; M u nson,
1993; Reinecke, Dattilio, & fre e m a n , 1996; S c h w eb el & Fine, 1994).
Historical Resynthesis

S u r v iv a l a n d B e l ie f s

Principles

If p erson al histories tau g h t clients their beliefs, w h y do th ey pre­

serv e so m e beliefs but reject o th ers? T he total n u m b e r o f beliefs a
client is ex p osed to is far g reater th a n th o se that b e c o m e part o f their
co g n itiv e system . Or, to put it a n o th e r way, w h y d o so m e Bs last and
b e c o m e p a n d e m ic in a client's life w hile others fade aw ay with just a
w hisper?
T h e sim plest a n sw er is th at so m e beliefs are m o re helpful to clients
th a n others. It's as if pragm atism is th eir teacher; pragm atism teaches
clients th ro u g h o u t th e ir lives to b eliev e in certain things a n d to look
at things in certain ways. If their ow n logic ca n 't prove w h y they
sh ou ld b e lie v e as th ey do, then so m u c h the w orse for their logic.
T heir e x p e rie n c e s h av e taught th em th ese sa m e principles over and
o v er again.
Clients' beliefs em erg e from th e p ragm atic interplay o f forces that
face th em . T h eir beliefs are ch o sen to solve specific en v iro n m en ta l and
so cial p ro b lem s th e y h av e encou ntered . T he patterns and schem es
th e y h a v e o f them selves an d th eir world exist b ec a u se they perceived
that th ese attitudes w ould help them c o p e w ith the w'orld. In m an y
cases, p o ssib ly in m ost, th ese attitudes hurt rather th a n help them , but
beliefs are selected for their perceived rath er th a n their actual utility.
It is v ery help fu l for th e therapist to ex p lo re the usefulness o f a client's
Bs alon g w ith th eir truth or falseness.

M eth od
1. Review y o u r client's m aster list o f beliefs
2. Help th em to d ecid e w h e th e r b e lie v in g these th ou ghts improves
th eir ab ility to solv e specific survival o r social problem s.
5. If the beliefs don 't help, assist th em in p lan n in g a strategy to change
them .
4. If th e beliefs w ere o n c e useful b u t aren't a n y longer, help the client
se e th e change.

E x a m p le
I give a h a n d o u t to s o m e o f m y clients to explain h ow h u m anity
has learned so m e o f its beliefs (see p ag e 302).
3Q 2_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T h e N e w H a n d b o o k o i- C o g n it iv e .T h e r a p y T e c h n iq u e s

HANDOUT: | |
IIOW H U M AN ITY LEARNE ITS ELIEFS 3 E
You may have learned som e o f you r beliefs through a process of
trial an d error. Imagine tw o cave m en, Zork an d Mervine, living in the
year o n e million b .c . It is late at night an d b oth are sitting in a cave by
th e fire, huddling from th e wind an d glacier cold. Suddenly they h ear
a loud, furious roar outside th e cave. Mervine's clear brain concludes
that it is a saber-toothed tiger. He builds th e fire higher a n d grabs his
club. Zork, o n th e other hand, has a fanciful brain. He conclu d es that
th e sound is the disguised siren call o f a voluptuous c a v ew o m an . He
puts on his n ew a n telo p e skin, rubs b ear grease in his hair a n d goes
outside for so m e earthly pleasure. Mervine survives with his clear B
brain, while Zork with his fanciful brain ends up in th e stom ach o f
th e saber- to o th ed tiger. Scratch o n e fuzzy brain a n d o n e fanciful B.
Centuries o f fanciful beliefs end ing up in th e tummies o f tigers
gradually selected for beliefs that are a little bit clearer. O ver time,
an cien t humanity's brain developed less clouded Bs; sc ien c e em erg e d
from th e blanket o f intuitive superstitions, research replaced implicit
authority, thinking em erged from blind d o g m a . It w as no longer
solely luck, authority, or revelation th at formed you r beliefs; it w as a
matter of survival.

%
 Ilistorical Resynthesis 303

C om m en t
In practice, y o u r clients will b e far less interested in how h u m a n ity
learned to b e lie v e certain attitudes an d far m ore interested in how
th e y learned th eir ow n thoughts. A historical search as to w h en the
beliefs w ere fo rm e d will help. You m a y find that originally the Bs were
a d ap tiv e and h elp ed th e client c o p e with th e e n v iro n m e n t they were
in at the time. W h at you m ay need to do is to sh ow you r client that
w h at was o n c e adap tive and helpful al a n earlier tim e is nonad aptive
and h arm fu l today.
If w e accept th e prem ise th a t clients c h o o s e beliefs b eca u se th ey are
p rag m a tically adaptable, h ow can w e explain th e following clearly
n o n u se fu l acts?

1. D oing s o m e th in g th a t physically hurts th e client, such as using

crack co ca in e , sm oking, o r drinkin g alcohol.
2. Engaging in activities that society p u n ish es them for, such as c o m ­
m itting felonies.
5. Sacrificing th eir se lf for a n o th er; for exam ple, charging a m a c h in e -
gu n nest or r u n n in g into a b u rn in g build ing to save a child.

W h a t is th e p ragm atic p ay off for these activities? According to prag­

m atic theory, p e o p le sh ou ld n 't d o th ese things, b u t th e y do. Is so m e ­
th in g w ro n g with th e theory?
D espite th ese exam ples, th e th eo ry is still correct. O u r m istake is
th a t w e d o n 't reco g n iz e the real payoffs for these beh aviors. Seeing the
rew ards w ould help us to u n d erstan d w h y clients keep b e h a v in g in
th e se ways. Let's lo o k at each o f th ese exam p les m o re clo sely
D oing things that h u rt us (like taking crack cocaine) doesn't co n tra ­
dict the theory, b ec a u se th e pain com es m u c h later, after the pleasure.
Clients w h o drin k to o m u c h or w h o use a d am agin g drug may seek
th e im m ed iate reward an d ig n o re th e lo n g -te rm conseq uen ces. The
im m e d ia te re in fo rce m e n t for m a n y drugs is a thing called "th e rush."
S o m e clients are stim u lu s ju n k ie s w h o love the feeling o f end orph ins
p u m p in g in their brains. T hese clients se ek a thrill, th e s a m e way so m e
p e o p le e n jo y roller coasters, driving fast, b u n g e e ju m p ing, o r skydiv­
ing.
T h e difficulty is th a t th e rush is tem porary, lasting o n ly a few m in­
utes o r hours. T he c o c a in e addict ev en tu ally will crash and the alco ­
h o lic will start g o in g th ro u g h withdrawal, but despite the days o f pain
t h e y kn ow th ey will face, m a n y clients c h o o se th e few m inu tes o f
pleasure. They m ay th in k that this tim e the pain w on't happen, or they
 T u t N ew H a n d boo k of C o g n it iv e T h e r a p y T e c h m q u e s

may sim p le ignore th e pain b e c a u s e th ey w an t th e p lea su re so m uch.

If th e payoff for ch em ical a b u s e is te m p o ra ry pleasure, th e n w h a t is
th e p ay off for crim inal activity? T he rush? T h e rew ards o f in tim id a ­
tion? T h e financial gain?
All o f th e a b o v e and still m ore. O n e o f th e m o st su rprising things
a b o u t cou n selin g crim inals is w h at th ey often tell th e m s e lv e s a b o u t
th e crim e th ey ju st com m itted . T he m a jo rity o f felons w e w o rk with
don 't th in k they did an y th in g w rong. By this w e d o n 't m e a n th a t they
insist th e y w ere in n o c e n t— a lm o st e v e ry b o d y in jail claim s in n o cen ce.
W h a t w e m e a n is th a t ev en th ose w h o privately adm it to h a v in g c o m ­
mitted th e crim e d e n y th at w h at th e y did was w ro n g ev en th o u g h it
was against the law. M o st con v icted felons offered a guiltless, b la m e ­
less reason for b reakin g th e law. T h ey h a v e told m e du rin g m y c o u n ­
seling interviews:

"Everybody steals, b u t I had th e b ad luck to get caught."

"Sh e deserved to b e b ash ed b e c a u s e sh e was su ch a bitch."
"Those rich p e o p le in th o se b ig h ou ses h av e all th e m o n e y ; I h a v e
none. I had th e right to b rea k in a n d ta k e all I could."
"I did the world a favor b y killing the bastard."
"I fenced th e g oo d s for m y friend b e c a u s e I w as ju st tryin g to help
him."
"I held up th e store b e c a u s e I n eed ed th e money?'
"I to o k a sw ing at th e c o p b e c a u s e h e w'as hassling m e. I had the
right."

I have cou n seled very few crim inals w h o th o u g h t th e y w ere b ad or

guilty for w h at th e y did.
This is a h u m a n trait. M a n y p e o p le find it e x trem e ly difficult to
th in k b a d ly o f them selves. Peoples' s e lf-c o n c e p ts requ ire th e m to see
them selves in the b e st possible light. T hey m a y h av e c o m m itte d so m e
horrib le acts, b u t th ey will s o m e h o w justify th e m to them selves. For
exam ple, so m e m ultiple rapists th in k o f them selv es as agents o f G od
p u n ish in g w o m en for their licentiou s ways. In their eyes th e ir acts
were n o t o n ly n ot evil, th ey w ere legitim ately g o o d : T h ey w e r e ca rry ­
ing out th e will o f G od b y rem o v in g evil w o m e n from th e w orld. It
appears that clients can rationalize a n y act if th e y try h ard en o u g h .
The p ragm atic gain for m a n y law breakers is not o n ly th e m o n e y
th ey m ake, th e ru sh th ey feel, or the frustration th e y express. It's also
the positive feeling th ey get from th eir ow n c o n v o lu ted ration aliza­
tions.
 Historical Resynthesis

T h e u ltim ate c o n s e q u e n c e o f th eir crim inal act is p u n ish m e n t—

im p riso n m e n t; a n d this they don 't like. But p u n ish m e n t doesn't
c h a n g e their b e h a v io r — a m a z in g ly they don 't c o n n ect the pu n ish­
m e n t w ith th e crim e. 1 h av e asked prisoners in jail, "How did you end
up in jail?" Few replied, "Becau se 1 violated th e law." Instead, most
answ ered, "Becau se Jo e turned m e in— th at son o f a bitch," or, "The
cops found th e crack in m y car w h en they pulled m e over for speed­
ing," or, "The bitch scream ed so loud after I hit her that the n eig h bors
called th e cops." W h e n I a sk th em , "W h at c o u ld you d o in the future
to avoid e n d in g up in prison again?" Instead o f saying things like, "1
sh o u ld n 't rob stores, deal cocain e, o r assault m y wife," they say, "I have
to get rid o f Joe!" "D on't sp eed w h e n you h av e crack in the car!" or,
Get m y s e lf an old lady w h o doesn't scream so much."
It proves a p oin t a b o u t p u n ish m en t. For p u n ish m e n t to work, it's
not e n o u g h for it to b e strong. W h at's m o re im p o rta n t is that the per­
son b e in g p u n ish ed sees the c o n n e c tio n b etw een his act an d his p u n ­
ish m ent. M o st law breakers don 't se e this con nection . Because o f their
distorted thinking, th ey don't b eliev e th ey did an y th in g wrong, so
th e re is n o reaso n for th em to stop th eir crim inal behavior.
Finally, w e are left w ith th e third con trad iction against beliefs b ein g
pragm atic, and this o n e seem s m ost telling. W h at could possibly be
th e rew ard for th o se h ero e s and h eroin es w h o give up their lives, w ho
sacrifice th em selv e s fo r others?
In s o m e cases it m a y b e sim ple— ad m iration o f humanity. "Isn't Mr.
Sm ith a w o n d erfu l h u m a n being?" is a very powerful reinforcer if you
are Mr. Sm ith. Even i f o n ly a few p eople watch a client's sacrifice,
clients can im a g in e all o f h u m a n ity applauding. How m an y you ng
m e n h av e pictured their girlfriends' adorin g gaze as they m entally
im a g in ed ch arging that m a c h in e -g u n nest? That fact that th e girlfriend
is u nlikely to think, "You are su ch a big, strong, w onderful hero," and
m o r e likely to believe, "I don 't w a n t to m arry an idiot w h o charges
m a c h in e guns," is irrelevant to th e fantasy.

F u rther Iu fo r m a tio u
Ju dith and A aro n Beck discuss h o w cogn ition s represent each indi­
vidual's u n iq u e solu tion s to th e p rob lem s o f juggling in n e r pressure
fo r survival and o f b attlin g external obstacles, threats, and d em an d s (J.
Beck, 1995; A. Beck, 1996).
So ciob iolog y, psychobiology, and p sy ch oev olu tion discuss the
306 T u t N ew H a n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

adap tive function o f certain beliefs, attitudes, an d co g n itio n s (see

Lungwitz & Becker, 1993; Van D er D e n n e n & Falger, 1990).
Edward W ilso n (1998) argues th at biological utility is at th e b ase
(consilience) o f social sciences, physical sciences, religion, philosophy,
a n d th e hum anities.
 Practice Techniques

r
V— is NOT p r i m a r i l y based on insight, b eca u se insight
o g n it iv e t h e r a p y

a lo n e is insufficient; sim p ly recognizin g that a th ou g h t is irrational is

usu ally not en o u g h to ch a n g e it. M a n y clients e n te r therapy know ing
that their th o u g h ts are illogical, and th ey are still u n a b le to respond
usefully w h en faced w ith strong en v iro n m en ta l triggers. S o m e per­
ceptu al shifting tech n iq u es like transform ation and bridging can pro­
du ce rapid, o n e -tria l learning shifts, but m ost others require repetition
and practice.
R ep etition is essential to countering. M ost clients have little n otion
o f h ow long a th ou gh t m u st b e disputed to ch a n g e it. If, for exam ple,
a client has rep eated an irrational th ou g h t 100,000 times, disputing it
for an h o u r o r so will do little to red uce it. Yet m ost clients b eliev e they
sh ou ld b e a b le to rem o v e a thou ght in a day or two, and certainly in
n o lon g er th a n a week. T hey th in k th a t b ec a u se they know that the
th o u g h t isn't true, th e y sh ou ld b e a b le to rem ove it easily. These clients
forget that th ou g h ts are habits, and like any o th e r h ab it they accrue
strength o v e r th e years. Just as clients can't learn to speak Spanish or
to play a cello in a week, th ey can 't c o u n te r their th inking instanta­
neously.
All o f th e tech n iq u es described in this ch a p ter require a great deal
o f practice. How m a n y repetitions are n eed ed varies from client to
client.
 T h e N ew Ha n d bo o k o e .C o c n i t m T h e r a p y T e c h n iq u e s

V isu a l P r a c t ic e

Principles

C ounters can b e m e m o rized in th e sa m e w a y th at foreign words

are, repeated again and again until th ey can b e u sed instantaneou sly.
Don't use a c o u n te r th at th e client c an 't r e m e m b e r on th e spot.
M em o riz in g co u n te rs speed s up th e d isp u tin g process. Initially the
client w on't recall cou nters until after the irration al th o u g h t has c o m e
and gone, b u t with practice co u n te rs can b e c o m e se co n d n a tu re, as
show n below.

A — B — Ce -------------------------------- t i m e ---------------------------- D

A = Situation
B = Irrational T h o u g h t or B elief
Ce = E m o tio n al Reaction
D = Disputing or C ou ntering

W ith practice th e c o u n te r m ov es b ack w ard in time, g e ttin g closer

and clo ser to interrupting the irrational thought.

A — B — Ce -------------------- D
A — B — Ce ----------------- D
A — B — Ce ------ D

(Ce is n ow ex p e rie n ced as a flash o f em o tio n , su ch as fear, lasting for

a b o u t 30 seconds.)
W h e n the client learns th e co u n te rs e x trem e ly well, th e disputing
cou n ters (Ds) will au to m atically o c cu r b e tw e e n th e A and B, p re v e n t­
ing th e negative e m o tio n from arising.

A ------------- D

M eth o d
1. Have th e client m a k e u p a set o f ind ex cards. O n o n e side o f each
card have the client write th e irrational th o u g h t an d rate how
strongly th e client b eliev es it o n a scale o f 1 to 10.
2. O n the o th e r side o f th e card h av e th e client w rite d o w n as m a n y
cou nters as possible.
Practice Techniques 309

3. Tell th e client to read th e card several lim es ev ery day, add ing o n e
c o u n te r each day. Record a n y c h a n g e in b e lie f level o n th e front o f
th e card.
4. R eading th e cards for 6 weeks gen erally reduces th e strength o f the
client's b e lie f b y at least half.

A u d it o r y P r a c t ic e

Principles

S in ce m o st clients report "hearing" their th ou g h ts rather than "see­

ing" th em , a u d itory m em o riz atio n is often effective. This tech n iq u e has
th e a d v an ta g e th at it can b e practiced w hile th e client is doing o th er
things, such as w ash in g th e dishes, clea n in g h ou se, etc.

M eth od
1. Record o n a cassette tap e a list o f the client's m a jo r irrational
thoughts.
2. Leave a b la n k sp ace o n the tap e after each thought. Instruct the
client to c o u n te r or record cou n ters to each th ou g h t o n the tape.
3. Have th e client listen to the ta p e and m a k e up new cou n ters daily.

C om m en t
Be sure to forew arn clients using this tech n iq u e that th e qu ality o f
th eir practice will vary; they'll have g o o d days and b ad ones. Like
m a n y o th e r procedures, practice tech n iq u es show im p rov em en t o f an
elliptical nature. Sin ce m ost clients ex p ect their irrational beliefs to
d ecrea se steadily, th ey m u st b e told to ex p ect b ad days in order to
avoid d iscou ragem en t.

F u rther In fo r m a tio n
T h e read er will recognize th e sim ilarity o f so m e o f these practice
te c h n iq u e s to W olp e's desensitization m e th o d s (Wolpe, 1958; W o lp e et
al., 1964), th e difference b e in g th e ad d ition o f th e cognitive c o m p o ­
nent.
O th e r practice proced ures can b e fou n d in th e w ork o f Ellis (1985,
1988a, 1995, 1998), M a h o n e y (1971, 1979,1993a), M a h o n e y and T h o r e -
sen (1974), M a u ltsb y (1990), an d R ichardson (1967). Ellis (1998) has
310 _ _ _ _ _ T h e N i.w H a n d b o o k h e C o g n it iy l T h e r m T e c h n iq u e s

clients play their practice tapes to o th ers w h o help m a k e co u n te rs

m ore vigorous and forceful. Further in fo rm a tio n a b o u t th e card te c h ­
n iq u e can b e found in th e works o f Beck (1998), M c G in n a n d Young
(1996), a n d Y oung an d Rygh (1994).

R o le - pla y in g

Principles

O n e o f the m ost c o m m o n difficulties w ith cogn itiv e th era p y is th a t

m a n y clients learn to dispute th eir th o u g h ts in a m ech an ical, u n in ­
volved fashion. O n e o f the b e st ways to co u n te ra ct this p ro b le m is by
role-playing, w h ic h is less rote and m o re realistic. A m o n g o th e r things,
role-p laying allows th e client to practice in situ atio ns th a t are m o re
akin to th o se th e y will e n c o u n te r in real life.
In this te c h n iq u e clients are forced to a ssu m e th e role o f a therapist.
This allows th em to d istan ce them selv es b o th from th eir p re o cc u p a ­
tion and from the intensity o f d efend ing th eir old position in front o f
the therapists. T h ey are forced to give m o re atten tion to th e p ossib le
sou rces o f their ow n m isp erceptions th a n th ey w o u ld otherw ise.
Elsew here in this b o o k w e h a v e n o ted th e passion w ith w hich
clients cling to their m istaken beliefs, ev en w h e n th ese beliefs cause
them pain. T hey m ay even e x p e rie n ce guilt if th e y allowr th em selv e s
to b e easily dislodged from th eir false perceptions. S o m e tim e s their
m otivation is far m o re basic— clients sim p ly d o n o t w a n t to a p p e a r to
b e "giving in" to the p ersuasive logic o f th eir therapists. R o le-p lay in g
is a te c h n iq u e th at preserves clients' self-esteem , lowers th eir resist­
a n c e to therapy (b eca u se th e therapist assu m es a passive, accep tin g
attitude toward th eir d am a g in g beliefs), a n d h o n e s th eir practice skills
so that they can b e tte r m o n ito r th eir o w n attitudes and b e h a v io rs in
th e future.

M eth o d
1. Use th e client's m a ste r list o f beliefs.
2. W ith th e client's help, co m p ile a c o m p a n io n list o f a rg u m e n ts to
these thoughts.
3. R o le -p la y an argum ent betw een th e ra tio n a l and irration al
th ou g h ts in w h ich th e client takes the ra tion al position a n d you, the
therapist, play o u t th e irrational argum ent.
4. Variations *
Practice Techniques 311
/

a. I h e th erap ist plays th e role o f th e person w h o originally taught

the false b e lie f to the client w hile the client argues against b oth
th e person and the belief.
b. U sing th e e m p ty -c h a ir tech n iqu e, have the client play b oth
sides— irration al b e lie f a n d cou n ters— arguing b o th for and
against th e core beliefs.
c. Help th e clien t to dissect irrational beliefs into c o m p o n e n t parts,
th e n role-p lay each part w hile th e client counters. For exam ple,
th e thought, "I could lose co n tro l an d em barrass m y self in front
o f others," has m a n y c o m p o n e n ts that can b e role-played. The
therapist could role-p lay th e part o f the client that wishes to be
in c o n tro l or that w ould b e em barrassed, the client's anxiety, o th ­
ers o b se rv in g th e client's em barrassm en t, etc., as th e client c o u n ­
ters each c o m p o n e n t.
d. In m ost cases, it is b est for th e therapist to m od el the ro le-p la y -
ing b e fo re the client attem pts it.

E x a m p le 1: Tlte Story o f Lynn

Lynn was a client w h o w as so afraid o f flying that she hadn't b een
o n a p lan e for 10 years. S h e had b e e n referred to m e by a b eh a v io ra l
therap ist w h o had used traditional desensitization for th e acrophobia.
T he treatm en t had b e e n successful in that the client could im ag in e all
o f th e item s o n her h ie ra rc h y w ith o u t tension, b u t s h e still wouldn't
g et on a plane. T he therapist had sent Lynn to see m e w ith th e h o p e
th a t a cogn itiv e c o m p o n e n t w ould take h e r o v e r the last step.
Lynn learn ed th e key c o m p o n e n ts o f cognitive th era p y after a few
sessions, b u t still actively resisted c o u n te rin g her irrational beliefs. Sh e
w as w illing to learn the intellectual c o m p o n e n ts o f cognitive therapy
m u ch as s h e h a d learned b e h a v io r therapy from th e b eh a v io r thera­
pist, b u t was recalcitrant in u sing this know led ge to help herself.
T h ro u g h o u t each session sh e w ould argu e against a n y direct sugges­
tion or instruction. U nw illing to accept a n y o n e else's advice, she
b elieved th at s h e shou ld b e ab le to solv e h er problem s herself. I
decided th at ro le-p la y in g w ould put h er argu m en tative nature to
g o o d use, e n a b lin g h e r to argu e against h e r ow n irrational thoughts.
T h e follow ing is a n excerp t from o n e o f m y sessions with Lynn.

THERAPIST: I w ould like to d o so m e th in g a little bit different for

this session. Instead o f y ou telling m e y o u r irrational b e lie f and
m e g iv in g you the counters, let's reverse it. I'll argu e for you r
312 T h e N e w H a n d b o o k o.e C o g n i t i v e T h e r a p y T e c h n iq u e s

b e lie fs a n d y o u a r g u e a g a in s t lh em ,^ okay ?
LYNN: I'm not sure I u n d erstan d w h at you m ean.
THERAPIST: Well, let's get started, a n d I th in k you'll get th e idea.
LYNN: Okay.
THERAPIST: I th in k y o u r fear o f flying is q u ite sensible. It's a
strange sensation to b e in this h u g e lum p o f m etal 30 ,0 00 feet in
the sky. And if s o m e th in g g o e s w ron g y o u can 't pull o v e r to the
side and get off.
LYNN: Yeah! It is scary.
THERAPIST: No, I w a n t you to argu e against me.
LYNN: That's hard b e c a u s e I b e lie v e w h a t y o u 're saying.
THERAPIST: I know, but try a rgu in g with m e anyway.
LYNN: Well, n o th in g will h ap p en , probably. It p ro b a b ly w o n 't crash.
THERAPIST: Probably, probably, that's n ot very reassuring. W h o
w ants to h av e his guts splattered all o v e r K an sas b e c a u s e you
m isju dged a probability?
LYNN: There isn't m u ch o f a c h a n c e so m e th in g b ad will h app en .
THERAPIST: M a y b e not. But sh o u ld n 't you take e v ery p ossib le pre­
caution?
LYNN: Like what?
THERAPIST: Like w orrying, or n ot gettin g o n planes, or freakin g o u t
o n c e you do.
LYNN: I don 't see h ow w orry in g w ould help in th e least.
THERAPIST: If you worry, then at least you 're prepared for th e d an ­
ger. You w ould n't w a n t so m eth in g to h a p p e n if you w eren't ready.
LYNN: That's silly. W orrying w on't keep th e p lan e from crashing.
THERAPIST: Well, I gu ess th a t m e a n s you h a v e to stay o ff planes.
LYNN: T h en I'd h av e to stay in o n e p lace all m y life.
THERAPIST: N onsense. You could drive a car, take a b u s, o r ev en
w alk if you had to.
LYNN: T hat w ould take t o o long.
THERAPIST: W h ich d o you w an t— to take a lon g tim e o r get
sm ashed like a pancake?
LYNN: Aw, c o m e on! I'm n o t.g o in g to get sm ashed. Besides, cars and
b u ses have m o re accid en ts th a n planes. And I could b r e a k a leg
or so m eth in g if I walked.
THERAPIST: O r get hit b y a cra sh in g plane.
LYNN: (Laughing) Yeah! I'd b e safer in a plane. At least I w o u ld have
m etal a ro u n d m e and I w o u ld n 't b e cau g h t o u t in th e open.
THERAPIST: Still, plan es are a lot scarier t h a n o th e r types o f tra n s­
portation. *
Practice Techniques 313

LYNN: So w h at? Feeling scared isn't g o in g to kill me. But c a r acci­

d en ts o r b u s accid en ts could.
THERAPIST: Yeah, b u t you could em barrass y o u rse lf o n th e plane
b y sh o w in g fellow passengers th a t you 're scared.
LYNN: E m barrass myself! W h o cares ab o u t that? That's nothing
c o m p a red to b e in g trapped in the sa m e place for the rest o f my
life. And all b e c a u s e I couldn't fly.
THERAPIST: You m e a n wouldn't fly!
LYNN: (Pause) Yeah! Wouldn't!

E x a m p le 2 : The Story o f B a rton

T h e following transcript sum m arizes a portion o f my exch an ge with
Barton, a client w h o sought counseling b ecau se his close friends had
b e e n telling him for years th at he didn't trust people enough; they had
told him that h e m u st b e paranoid. This edited transcript is near the end
o f the role-playing session in w hich Barton and I had reversed roles.

THERAPIST: This th o u g h t th at p eople can't b e trusted is absolutely

true. T h ere are p ro b a b ly a th o u sa n d exam p les o f y o u r being
taken a d v a n ta g e o f by so m e o n e w h om you had thou ght you
c o u ld trust. It's b est n o t to trust anybody, but to treat all people
like they are trying to m an ip u late you, and to guard against their
d o in g so.
BARTON: But so m e p eople have treated m e fairly.
THERAPIST: For now! But just wait 'til th e future
BARTON: W h a t d o I get for covering m y ass all th e time? No friends
and lots o f enem ies.
THERAPIST: At least you w o n 't b e taken like you have b e e n for the
last 15 years.
BARTON: But that's a b ad exchange. No friends, lots o f enem ies, and
w hat d o I get fo r all this protection? I can put a b a n n e r on my
wall w h e n I am d y in g a lo n e and friendless. It will read, "HE
N EVER LET ANYBODY TAKE ADVANTAGE O F HIM!" Big deal! It
w ould n't b e w orth it.
THERAPIST: But if you let y o u rse lf get ta k en it will sh ow ev ery b o d y
w h a t a sch m u ck , w hat a w eakling you are.
BARTON: It would o n ly sh ow th at 1 win so m e and lose som e, like
e v e ry b o d y else. A real sc h m u ck w ould b e a gu y w h o throws
aw ay all closen ess just so s o m e b o d y doesn't take adv antag e of
him. Now, that w'ould really b e du m b!
314 T h e N ew H an d bo o k of C o g n it iv e . T h era py T e c h n iq u e s

THERAPIST: How could y o u have a n y s^ lf-esteem if you don 't p ro­

tect y o u rse lf from others?
BARTON: Do I have a n y se lf-e steem now, w ith m y p resent attitude?
THERAPIST: That's b e c a u s e you have n ot d o n e a very g o o d jo b o f
guarding.
BARTON: I don 't know o f a n y b o d y w h o gu ards m o re t h a n I do, and
I've paid th e price fo r it. I h av e no friends, n o lover, and despite
all th e guarding, so m e p eople are still ab le to take a d v a n ta g e o f
me. It's not worth it a n y m o re. Better I stop p rotectin g all th e tim e
a n d o p e n up to people, a n d if I get hurt, th en so w h a t? It w ould
still b e b etter th a n w h a t I have now.
THERAPIST: You h av e a g o o d p oint there. I can't a rg u e ag a in st it.

C om m en t
Besides b e in g a g o o d treatm en t tech n iq u e, ro le-p la y in g can b e used
to assess how solidly clients h a v e in corp orated th eir new beliefs.
Clients w h o have ju st m em orized th e m will b e u n a b le to a rg u e with
th e therapist. T hey give up the a rg u m e n t q u ick ly an d agree w ith th e
therapist. In th e a b o v e exam ples, th e clients d e m o n stra ted th a t they
u nd erstoo d th e n ew beliefs— not ju st th e words, b u t th e c o u n te r p h i­
lo so p h y b e h in d th em as well.
This tech n iq u e can also b e useful for clients w h o o p p o se th e c o u n ­
selor's direction, particularly w h e n this b e h a v io r se em s to b e part o f
their social repertoire. Such clients are high ly m otivated to win an
argum ent, even if it m e a n s giving up th eir irrational thoughts. W h e n
ro le-p lay in g is used in this way it is a parad oxical tech n iq u e. If client
a n d c o u n se lo r d o not sw itch roles, ro le-p la y in g is a c o u n te rin g tech ­
nique.

F u rther In fo r m a tio n
T h e role-p laying te c h n iq u e is a significant part o f sc h e m a -fo c u s e d
th erap y (Bricker, Young, & Flanagan, 1995). T he te c h n iq u e s m e n tio n e d
are a cognitive ad ap tation o f s o m e o f th e p roced u res d ev elo p ed b y
gestalt therapists. T h e read er m ay find it useful to refer to s o m e orig­
inal sources, such as Fagan and Sh ep h erd (1970), Feder and Ronall
(1980), H atcher and H im elstein (1996), M a c K ew n (1996), Nevis (1995),
and the creator, Peris (1969a, 1969b, 1975).
R ole-sw itch in g is used in m a n y fo rm s o f p sy ch o th e ra p y (see
Corsini, 1957, 1981, 1998; G reen berg, 1974; M o r e n o & Zeleny, 1958).
Practice Techniques 315

E n v ir o n m en t a l P r a c t ic e

Principles

E n v iro n m en ta l practice is a te c h n iq u e that solidifies therapeutic

g ain b y providing clients with an op p o rtu n ity to practice cognitive
c h a n g e s in real-life situations. Hence, clients are urged to en g age in
t h e avoided b e h a v io r to prove that n o h a r m will actually befall them.
R ep eated testing u n d e r th e overt con d ition s w hile practicing cognitive
te c h n iq u e s also helps clients realize that w h at has w orked covertly
will also w ork in vivo.
It is u su ally n ecessa ry for clients to try out their cognitive changes
in real life. W h ile so m e clients don 't actu ally have to test their beliefs
to b e c o m e c o m fo rta b le w ith them , m ost clients need to try th e m out.
E lim in atin g their old beliefs totally b y covert, cognitive m eans usually
leaves th e lingering thought, "Yes, b u t I haven't actu ally d on e it, yet"
(e.g., get o n th e plane; ask h er for a date; sp eak in public; ta k e the test,
etc.). For su ch clients, e n v ir o n m e n ta l practice is a v alu ab le last step for
all cogn itiv e tech niqu es.

M ethod
1. List th e co re beliefs co n n ec ted to y o u r client's problems.
2. Teach all aspects o f covert, countering, perceptual shifting, or other
cogn itiv e tech n iqu es with these beliefs.
3. After discu ssing it w ith y o u r client, develop a conclu siv e e n v iro n ­
m en tal test o f th e beliefs. For exam ple, you could test the thought,
"I could g o crazy if I travel far from h om e" (the agorap hobic's fear)
b y suggesting y o u r client travel 6 miles, th en 1, th en 15, etc. Develop
a test for each irrational thought.
4. T h e client then actu ally perform s th e tests and records the results.

E x a m p le : The Story o f Jo h n
Jo h n was a y o u n g m a n w h o entered therapy to rem ove his c o m ­
pulsive b eh a v io rs. Every day h e p erform ed 4 0 or 50 m eaningless ritu­
als to red u ce anxiety. He had seen several o th e r therapists but the
fr e q u e n c y o f his rituals had not b e e n reduced.
He had m a d e a lot o f covert ch a n g es b u t h ad n 't actu ally red uced
his rituals in his en v iro n m en t. W e first identified w h a t h e said to h im ­
se lf im m ed iately b efo re p erform in g the rituals and found m an y
beliefs.
116 Tut Ntw H an d bo o k of C o g n it iv e T iitiu rr T k f in iq u e s

• If I d o n 't d o th e rituals, s o m e cata stro p h ic th in g will h app en.

• Rituals protect m e from danger.
• I m u st have p eople like a n d respect me.
• I m u st alw ays b e in control. I c a n n o t let m y s e lf feel s o m e th in g that
I don 't control.
• I h av e th e p ow er to m ak e m y se lf feel a n y th in g 1 want.
• Rituals exercise this power.
• If I give u p the power, I will b e in great danger.

W e then used hard an d soft c o u n te rin g a n d p e rce p tu a l shifting

tech n iq u es to c h a n g e his beliefs. He first practiced all th e cogn itiv e
tech n iq u es covertly, w e taped th e sessions, and h e practiced th e tech­
n iqu es at h o m e several tim es a week.
W e then decided to try the te c h n iq u e s in vivo. T he first e n v ir o n ­
m ental practice used a sin g le -su b je ct e x p e rim en ta l design. He c o n ­
ducted a study with h im s e lf to c o m p a re th e effects o f d oin g th e ritual
v ersus doing a cogn itive tech niqu e. He did th e e x p e rim e n t for five
weeks. W e used an individual tim e series design.

01 Xn 02 05
-----------------------------tim e ------------------------------

with Os = self-rating o f an xiety level o n a 1 -1 0 scale.

with 01 = his tension level im m ed iately b efo re h e en g aged in the
ritual.
with 02 = his an xiety im m ediately after h e eith er did th e ritual or
did so m e alternative treatm en t (Xs).
with 03 = his anxiety 15 m in u tes later.

The in d ep en d en t variable (Xn) stands for:

X - l . Doing the ritual.

X -2 . Not doing th e ritual.
X -3 . Substituting relaxation for th e ritual.
X -4 . Finding th e thou ghts causing th e an xiety preceding th e ritual.
X -5 . O b jectively analyzing th e tru th or falseness o f th e thoughts.
X -6 . Contradicting, challenging, and disputing his thoughts.
X-7. Sw itching to a n o th e r ritual.
X -8 . Finding th e en v iro n m en tal trigger preceding th e an xiety and
ritual.
X -9 . Im agining a relaxing scene.
X —10. C hanging the v is u a l c o m p o n e n ts o f th e ritual.
Practice Techniques 317

X - l l . D oing so m eth in g b eh a v io ra lly assertive in the situations.

X -1 2 . C o u n terin g his fears w h en h e d o esn 't d o ritual.

Sin ce Jo h n averaged 4 0 rituals a day b efo re treatm ent, I told him to

picture four or five tim es each day w h en h e would record his anxiety
an d try to interrupt the ritual by doing s o m e th in g else (independent
variable). Table 11.1 sh ow s w h ich interru ption (Xn) helped most.

Ta b l e i i .i

M ean Self-ratings o f Anxiety (10-0) During Different Time Periods (Os), in

Different Experimental Conditions (Xs). N = 175 trials.

m ean change
01 Xn 02 03 ( a n x ie ty
r e d u c tio n )

3 .7 5 1 0 0 -3 .7 5
4 .1 7 2 5 0 -1 .6 7
3 .6 7 3 1.8 3 - 1 .7 9
3 .7 5 4 to 6 1.02 0 - 2 .7 3
3 .5 0 8 1.05 0 - 2 .4 5
3 .0 0 10 1.00 0 - 2.00
4 .0 0 11 .71 0 - 3 .2 9
3 .0 0 12 1.00 0 - 2.00

T h e study sh ow s several im p o rta n t data: (a) His rituals reduced the

a n x ie ty m o re effectively than a n y o th e r techn iqu e. That was w h y he
was obsessive, (b) W h e th e r he did th e ritual or not, his anxiety left
after 15 m inutes, usually in a m inu te o r two. (c) Besides d o in g the rit­
ual, identifying and co u n te rin g his th o u g h ts reduced his anxiety the
m ost (4 to 6 SUDS); finding th e en v iro n m en ta l triggers (8), and doing
s o m e th in g assertive in th e situation (11) also helped.
A fter the stu d y w e decided to try en v iro n m en ta l practice. He was
told to use his m ost effective in terven tion tech n iq u es to reduce th e rit­
uals; th e p roced u re w ould take 85 days. Each day he was allotted a
certa in n u m b e r o f lim es h e could en g age in ritualistic behavior. He
could n ot d o rituals if h e had fulfilled his daily allotm ent. W h e n he
a p p ro a ch e d his daily limit he was told to c o u n te r his thoughts, find
th e e n v ir o n m e n ta l CSs, and d o so m eth in g assertive instead o f doing a
ritual. He w o u ld m o n ito r his practice with a hand counter. T h e fol­
low ing is a record o f his e n v iro n m e n ta l practice.
318 Th e N ew H a n d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

Day RitualsV Allowed Rituals Used

1 40 26
2 59 25
3 58 54
4 37 26
5 36 30
6 35 22
7 34 21
8 33 28
7 32 17
8 31 17
9 30 14
10 29 13
11 28 19
12 27 19
13 26 14
14 25 25
15 24 17
16 25 15
17 22 16
18 21 21
19 20 14
20 19 15

T h e ritual b e h a v io r grad ually reduced. This red uction con tin u ed .

31 9 10
32 8 9
33 7 8
34 6 8
35 5 6

At this point h e was g o in g o v e r his daily lim it so w e shifted th e

approach. Each w eek h e was allotted a m a x im u m b u t d ecreasin g
n u m b e r o f rituals. If h e w e n t o v e r his a llo tm e n t o n e d ay h e h a d to
take it from the n ex t day's allotm ent. Finally, o n day 70, h e en g a g ed in
n o rituals.

70 2 0
71 2 1
72 2 2
73 , 2 0
Practice Techniques __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 312.

/
74 1 0
75 1 1
76 1 0
77 1 0
78 1 0

W e c o n tin u e d th e practice until he con sistently didn't d o th e rituals.

C om m en t
As th e last step in CRT, w e alm ost alw ays have clients practice their
te c h n iq u e s in real-life situations. W ith o u t this p roced u re m ost clients
feel that th ey haven't really com p leted their work.

F u rther In fo r m a tio n
Several a u th o rs h av e d eb a ted th e necessity o f en v iro n m en ta l prac­
tice for cognitive te c h n iq u e s (see Bandura, 1977a, 1977b, 1982, 1984,
1995, 1996; M ah oney, 1993a; and M e ic h e n b a u m , 1993).
O th e r au th o rs rem ark that e n v iro n m e n ta l practice is the o n ly nec­
essary c o m p o n e n t for b e h a v io ra l c h a n g e and that w o rk ing o n co g n i­
tion s m a y b e su p erflu ou s (Hawkins, 1992; Hayes, 1995; Skinner, 1953,
1974, 1991).

D ia r y R esea r c h an d P r a c t ic e

Principles

All co g n itiv e te c h n iq u e s sh a re a m a jo r p ro b lem — th e therapist

does not k n o w for certain that th e p roced u res are g o in g to work.
G en e ra lly it is n o t bad to a ssu m e th eir efficacy, for th ey h a v e b e e n
tested o n th o u sa n d s o f clients at clinics th ro u g h o u t th e world. But
e v e ry n ew clien t e n te rin g therapy presents a special challenge, and
w e c a n n o t b e certain th a t a specific te c h n iq u e will b e effective sim ­
ply b e c a u s e it has h elp ed others.
It's b est to discov er w hat works for a particular client in a specific
situ ation th ro u g h ex p e rim en ta tio n rather th a n b y follow ing a favorite
t e c h n iq u e or two. T h e easiest, m o st logical, or m ost clever cou n ters
m a y h av e h elp ed h u n d red s o f clients, and may even have had scores
o f b o o k s w ritten a b o u t them , b u t w h a t g o o d are they if they don't
help the client sitting in front o f you ?
320 T h e N ew H a n d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

T he p u rp o se o f diary research is to h elp clients find an d p ractice th e

m ost effective cou nters b y ex p erim en ta tio n .

M eth o d
1. H ave clients keep a record o f all the te c h n iq u e s th ey h a v e found
effective in red u cin g a n x iety o r o th e r n eg ativ e em otions.
2. For each te c h n iq u e h av e clients record, on a series o f 1 0 -p o in t
scales: (a) th e streng th o f the em o tio n b e fo re th e tech n iq u e, (b) th e
streng th o f th e tech n iqu e, (c) h o w long th e te c h n iq u e was used, an d
(d) th e strength o f th e em o tio n after using th e tech n iqu e.
3. T h e b est tech n iq u es are th o se th at rem o v e a strong n eg ativ e e m o ­
tion. Clients sh ou ld b e esp ecially careful to keep accu rate records
on th o se te c h n iq u e s that re m o v e o r red uce a n x iety attacks o r severe
depressive episodes.
4. After a sufficient n u m b e r o f w o rk a b le tech n iq u es h av e b e e n g a th ­
ered, h av e clients c h o o s e th o se that p rod uced th e greatest red uc­
tion s in negative em otion s. Next, instruct clients to d ev elo p a w h o le
new series o f tech n iq u es em p h asiz in g th e key p oin ts in p reviou sly
successful procedures.
5. Have clients c o n tin u e to refine th ese te c h n iq u e s b ased o n trial and
error. Eventually clients will d ev elo p so m e very' pow erful, effective
techniques.
6. In m a n y cases it is also useful to h av e clients recall all o f th e tech ­
niques th e y used th ro u g h o u t th eir lives w h en c h a n g in g th e s a m e
or sim ilar thoughts. O ften th e te c h n iq u e s that w o rk ed esp ecially
well in the past will c o n tin u e to w o rk well in th e future.

E x a m p le: T he Story o f David

Following are so m e excerpts from th e te c h n iq u e diary o f a clien t w e
will call David, a 3 1 -y e a r -o ld professional w h o had w e ek ly a n x iety
attacks for several years. T h e trigger for th ese attacks w as alw ays the
th ou g h t that h e would g o insane.
T h e attacks had started after a relative o f David's was institutionalized
for severe em otional difficulties. Although David had absolu tely no
sym ptom s o f psychosis, h e lived in mortal terror o f b eco m in g schizo­
phrenic. He was stricken with anxiety w h en ev er h e was exposed to p eo­
ple, movies, or conversations that depicted o r m entio ned insanity or
abnorm al b eh avio r o f a n y kind. O n e year o f psychoanalytic therapy and
six m o n th s o f behavioral desensitization h a d not reduced his anxiety.
Practice Techniques 321

David was u n a b le to attend th erap y o n a regular basis so we

decid ed h e sh o u ld use th e diary techniqu e, w hich can b e d o n e al
h o m e . He rep orted to m e periodically by phone.
For o n e y e a r he k eep a careful record o f all the tech n iq u es that were
effective in red u cin g th e severity o f his a n x iety attacks. O n c e a m on th
h e was to rate th e effectiveness o f each techn iqu e.
Based o n his research David was a b le to develop increasingly effec­
tive tech n iqu es, significantly red ucing th e fre q u e n c y and intensity o f
his a n x iety attacks in o n e year's time. He c o n tin u e d the diary after we
term in a ted his therapy. T h ree years later, he was entirely free o f an x i­
ety attacks.

E x c e r p t s f r o m David's Diary'
(These are the m ost effective techniques he tried when he h ad anxiety attacks. The
ratings o f h ow effective they were are included.)

Technique No. 145. Look at y o u r a n x iety like this— it's just catastro­
phizing. C on sid er th e trou b les that others have, and how upset they
deserve to be. Your p rob lem s are con sid erably less th a n theirs, but
you catastrop h ize co n sid erab ly more. (David rated the effectiveness
o f this te c h n iq u e at 2.4 o n a scale o f 10.)
No. 146. T h e fear you h av e now is th e sam e o n e you had years ago.
T h e o n ly differen ce is that now you 're calling this feeling crazy.
(5.4/10)
No. 147. Look a ro u n d at the reality. Ign ore y o u r em otions. (2.9/10)
No. 148. T h e flaw in m e is a flaw in life. (1.9/10)
No. 149. R e m e m b e r and retrace y o u r history' o f catastrophizing. You
are d o in g it right now. Stop it! (5.7/10)
No. 150. D on't try so hard to get rid o f y o u r em otions. The anxiety
you feel isn't so terrible— and con cen tratin g on it o n ly m akes it
worse. So ju st wait for it to g o away. C on sid er it as a cold— a tem ­
porary n u isa n c e that doesn't really require m u ch attention. (7.3/10)
No. 151. B e co m e e x trem e ly assertive and goal-directed . (3.7/10)
No. 152. You are b e in g su p e r-d ra m a tic again. Get real. (5.2/10)
No. 153. You have had o v e r 3 0 0 anxiety attacks. Every single time
you w ere afraid you were g o in g crazy, b u t n o th in g has ev er hap­
pened. So big deal! This is ju st a n o th e r one. (8.1/10)
No. 154. You are an x io u s b e c a u s e y ou learned to b e an d you can
u n le a rn it. (4.6/10)
No. 157. You can stand to b e scared for a little while. You don't have to
get rid o f it, or get in a stew every time you feel a little bit upset. (4.1/10)
322 The N ew H an d bo o k of C o g n it iv e T h e r a p y T e c h n iq u e s

No. 158. You're getting a n x io u s in this situ ation b e c a u s e y ou think

y ou sh o u ld get anxious. If you th o u g h t you sh o u ld get an x io u s
b e c a u s e you picked y o u r nose, th en picking y o u r n o s e w ould m a k e
you an xiou s. (3.6/10)
No. 159. You h av e n o alternative. If you are g o in g to g o crazy, th e n
it's g o in g to h app en . You can't prevent it no m atter w h at you do, so
you m ight as well b e as ha p p y as you can in th e m e a n tim e. G o
a h ead an d e n jo y life w h ile you still can. (8.9/10)
No. 160. G row up! Stop b e in g a little b aby! A little fear isn't g o in g to
kill you. (1.0/10)
No. 161. Give y o u rse lf a break! There's no p o in t in b la m in g y o u rse lf
for you r fear. You didn't try to get it, so stop attack in g yourself.
(4.4/10)

W h en David was interview ed after h e got o v e r his anxiety, h e said

that tw o tech n iq u es u ltim ately rem oved his fear. T he first was th e idea
that fear had n o th in g to d o with b e in g crazy; it w as ju st a learned
p hobia. T he second was th at th e p u rpose o f h u m a n life is n ot sim p ly
to protect o n e s e lf from every c o n ce iv a b le threat. O urs is the d o m in a n t
species on this planet b e c a u s e historically w e h a v e taken risks. There
are n o g u aran tees for a n y o f us. O n e can see the origin o f b o th o f these
ideas in David's diary.
An u p d ate o n David: Me hasn't had m a jo r a n x iety fo r o v e r 15 years
now. In look in g back at w h at h e did to get rid o f it, David n ow c o n ­
cludes that N u m b e r 159 in his dairy was th e key. ‘Y o u h a v e n o alter­
native. If you are g o in g to g o crazy, th e n it's g o in g to h a p p en . You can 't
p revent it no m atter w h a t y ou do, so you m ight as well b e as ha p p y
as you can in th e m ean tim e. G o ahead and e n jo y life w h ile y ou still
can. (8.9/10)."
David got h im s e lf to accept his anxiety. T he a cce p ta n ce w as not just
a verbal counter, but a firm, d eep belief. He had b e e n crea tin g his ow n
an xiety all along, yet d e m a n d in g o f h im s e lf th at h e get rid o f it. He had
b e e n telling h im s e lf that it was a b so lu tely terrible, h orrib le, an d c a ta­
strophic that he h ad a n x iety attacks, th a t h a v in g th em sh o w ed a fu n ­
dam en tal w eakness, th at h e cou ld n 't stan d to live w ith th em , and that
h e had to get rid o f th e m at all costs. He finally told him self, "T h e hell
with it. I h a v e sp en t to o m u c h tim e in m y life trying to get rid o f this
anxiety. I d o n 't w ant to w aste a n y m o r e tim e. Tough shit th a t I h a v e
to live with a n x iety attacks. I ju st will h a v e to. Now let's m o v e on."
W h e n h e b elie v ed this, his a n x ie ty attacks disappeared. Ellis is c o r­
rect— w h en David removed, his m u sterb atio n , h e rem oved his fear.
Practice Techniques 323

/
C om m en t
This client found th e diary highly beneficial, b u t it deserves m e n ­
tion th at h e had a strong b a ck g ro u n d in psychology and read ex te n ­
sively in th e area o f cogn itive/beh avioral th erap y th rou g h ou t the year
h e was u n d e r treatm ent. M o st clients need m ore help from their ther­
apists.

Further In fo r m a tio n
Ira Progoff (1977, 1992) h a s develo ped a c o m p reh en siv e set o f m eth ­
ods called in ten siv e jo u rn a l therapy, th e use o f diaries and jo u rn a ls in
psychotherapy. His approach has a p sy ch o d y n a m ic u n d erp in n in g as
o p p o se d to o u r procedures.

G u id e d P ra c tic e

Principles

G uided practice puts several m a jo r cognitive tech n iq u es together in

th e s a m e exercise. Because cognitive th erapy involves subtleties that
clients o ften miss, it is b est to gu ide them step b y step through the
variou s procedures, correctin g m istakes as they occur. After several
practice sessions clients usually m aster th e tech n iq u es well en o u g h to
e m p lo y th e unified proced ures in real-life situations.

M eth od
1. Attach a b io fee d b ack m easu re (GSR, EMG, o r pulse rate) to your
client. O b se rv e th e m e a su re for five m in u tes to o b tain a baseline
reading.
2. In d u ce relaxation. Stand ard relaxation, hyp notism , deep b rea th ­
ing, p in k o r w h ite noise, n a tu re images, o r b io fee d b a ck response
red uction are appropriate. Allow the client to stabilize on the
selected b io fee d b a ck m e a su re b efo re proceeding.
3. Prepare a hierarchy o f upsetting scenes and have the client im ag­
ine th e first item o n th e hierarchy.
4. Ask th e client to tell you the b e lie f causing the pain. Allow all the
tim e n eed ed o n this step, until th e client is a b le to articulate the
b e lie f in a co re se n te n c e o r two.
5. Help th e clien t find th e p h ilosop h y u n d erly in g the surface
324 T h e N ew H andbook of C o g n it iv e T h e r a p y T e c h n iq u e s

thou ght. Probing q u estio n s like, "So w h a t i f . . . ? W hat's so terri­

b le i f . . . ?" can b e used to ro o t o u t co re beliefs.
6. A nalyze each c o r e b e lie f and help the clien t d e cid e w h e th e r it is
useful o r not useful.
7. If a core b e lie f is n ot useful, help th e client ch a llen g e an d dispute
the th ou g h t as deeply as possible, using all th e e v id e n c e availab le
to ex p o s e it as faulty. C o n tin u e this attack u n til th e b io fee d b a ck
m e a su re show s a reduction in th e painful em otio n .
8. Repeat th e exercise, sp eed in g up the p ro ced u re until th e client's
b io fee d b a ck reading rem ains th e s a m e w h ile th e sc e n e is b e in g
imagined.
9. E n cou rage th e client to sp e a k o u t loud du rin g th e en tire p ro c e ­
dure. This will e n a b le you to assess th e client's ability to c o u n te r
and dispute.
10. Tape the session a n d have th e client practice it 4 o r 5 tim es a w eek
for several weeks.

E x a m p le : The Story o f M artin

T he following transcript is an excerpt from a g u id ed practice session
with M artin, a 3 5 -y e a r -o ld professional m an w ith m u ltiple problem s.
M artin fluctuated b e tw e e n p eriods o f a n x iety an d d epression, h a d a
history o f drug and alcoh ol abuse, an d avoided all m a jo r risk -takin g
behaviors.
After several sessions, w e fou nd M artin's co re p h ilo so p h y : He
believed th at ev ery o n e sh ou ld respect h im all th e time, in ev ery situ­
ation im aginable. He panicked at th e m e re th o u g h t o f rejection and
felt deeply depressed w h en h e ex p e rie n c e d it. He h a d a p p a ren tly
learned his o th er-d irected p h ilosop h y from a n overly perfectionistic
father, w h o had pushed for im p o ssib le ach iev em en ts. As is tru e for
m an y clients w ith this back grou nd , h e felt h e w ould n ev er acco m p lish
e n o u g h to gain his father's respect.
M artin co n stan tly search ed for respect. He b e c a m e t e n s e w h e n e v e r
h e anticip ated rejection and cop ed b y in crea sin g his perfectionist
d e m an d s on himself, creating in ten se in tern al pressure. His a n x iety
would then accelerate into p an ic— w h ich o n ly p rod u ced m o r e failure.
Trapped in a vicious cycle, h e w o u ld th en red o u b le his d e m a n d s on
h im self until th e o n ly way o u t was to tu rn to drugs an d a lc o h o l to
s o o th e the pain.
B iofeedback tech n iqu es w ere used to teach M artin relaxation. A
m easu re was used to read^ his skin conductivity. T h e unit has a skin
Practice Techniques

resistan ce ran ge o f 5 0 0 0 to 3,000,000 oh m s, and a m eter/tone resolu­

tion < 0.20/0 o f b a se resistance o f O .sR O S C ). Inputs consisted o f ex ter­
nal finger electrodes. O u tp u t was provided o n a dual sensitivity m eter
grad u a ted into 4 0 units, w h ich could b e sw itched to a sub/superior
d isp la cem e n t o f 4 0 add itional units, creating an 8 0 -u n it range.
D uring the first 15 m in u tes o f th e session M artin practiced relax­
ation w h ile b e in g m o n ito red for skin conductivity, p rod ucing a
decrease o f 35 units. H e m a in ta in ed this rate during a fiv e-m in u te
b a se reading period, after w hich the m e te r was reset at the central
z e ro -d isp la ce m e n t level.
The follow ing is a transcript o f the instructions I gav e to M arlin. The
figures in p a re n th e ses are the a m o u n t o f tim e elapsed, and increases
(+) a n d decreases (-) in g alv a n ic skin resp onse (GSR).

I w o u ld like you to close y o u r eyes and im ag in e the next

sc e n e in y o u r hierarchy th at causes anxiety. Im ag in e it as vividly
as y ou can and use all o f you r senses until it is clearly in mind.
W h e n y ou se e it, indicate this b y slightly raising y o u r finger. (43
se co n d s; +12)
(Martin im agined h im self at work. Because o f a new prom otion, he was
now supervising 2 0 people he had w orked with fo r several years as a col­
league.)
Very g oo d . Now keep im agining th e situation, but con cen trate
o n w h a t you are say ing to yourself. Take y o u r time, b u t focus on
the first th o u g h t th at pops into you r h ead that's co n n ected to
y o u r anxiety. Try to ca p tu re it and see if you can put it into a sen ­
tence. Ind icate w h en you are ready. ( 23 seconds; + 1 6 )
Now, as w e h av e discussed before, I w a n t you to lo o k u nder­
n e a th th e surface. Im ag in e y o u r th ou g h ts are con structed like an
u p sid e-d o w n pyram id. At th e top the sh allow beliefs sit, b u t the
o n e o n th e b o tto m holds up all the rest. I w ant you to start m o v ­
ing dow n th e pyram id till you find the core. Look at the first
b e lie f a n d ask y o u rse lf th e question, "So w hat i f . . . ?"
(His first thought was that everybody w ould be very angry with him fo r
being prom oted over them.)
I had h im c o u n te r with, "So w h at if th ey are angry?"
I said, "Take all the time you need, b u t wait until you h av e an
answ er" (12 seconds)
"Then th ey w o u ld n 't like o r respect me."
"Now keep o n ask in g y o u rse lf th e qu estion , 'So w hat if?' or
'W hy?' Take y o u r tim e until you have an answer, and m ov e on
326 T h e N ew H an d bo o k of C o g n i t iv e T h fra py T e c h n iq u e s

to th e n ex t statem en t. C o n tin u e until you can find n o fu rther

beliefs." (1 m in u te; +8)
(The most basic though! M artin discovered was, “It w ould be absolutely
horrible if som ebody didn 't respect me.")
Keep im a g in in g the s a m e situ ation a n d keep rep eatin g th e
th ou g h ts to y o u rse lf until you are sure you can r e m e m b e r them .
Indicate w h en you are don e. (55 secon d s; +8)
Take s o m e m o re tim e ju st to relax. M a k e y o u r m uscles loose,
lim p an d slack. (30 secon d s; -8)
Keep relaxing but get so m e d istan ce from y o u rse lf a n d start
look in g at each th ou ght, o n e at a time. M a k e a cold ly objective,
n o n e m o tio n a l decision as to w h e th e r each th o u g h t is true or
false, using all th e tech n iq u es I h av e p reviou sly tau g h t you. Take
y o u r tim e b u t b e sure to m a k e th e m ost o b je ctiv e decision you
can. (I '/a m in u tes; +6)
(He decided that the first thouqht w as true but that the next two were
false.)
Im ag in e the situ ation again and picture th in k in g the first
th ou g h t that you ju d ged false. Keep d o in g this u n til it's clearly in
mind. (54 seconds; +10).
Now attack, challenge, contrad ict that th o u g h t in e v ery way
you can. C o n v in ce y o u rse lf th a t it is false, u sin g all th e ev id en ce
you can find against it. C o n tin u e until you feel a defin ite lessen­
ing in the belief. Indicate w h en you are done. (4 m in u tes; +2).
Take th e n ex t b e lie f you logically kn ow is false b u t still aren't
co n v in ced o f and do th e s a m e thing. D ispute it as hard as you
can and keep d o in g it until you feel m o re con v in ced . ( 2 x/r, -3).
Okay, n ow relax again. (45 secon d s; -20)
Now ju st as a check, im a g in e th e first scen e again ju st as you
had first im ag ined it. (98 second s; -12).

We repeated the exercise tw ice more, in creasing th e speed du ring

each repetition. W h e n the test scen e w as presented the last tim e, M a r­
tin's G S R reading was -27, from th e b a se lin e relaxed state w h ere it
rem ain ed th ro u g h o u t th e session. In later sessions, w e used th e sam e
te c h n iq u e to red uce his a n x iety a b o u t th e o th e r h ie ra rc h y items.

C om m en t
The guided practice ap p ro a ch is an e x trem e ly useful th e ra p e u tic
techniqu e. A lm ost all clients h av e practiced it du rin g therapy. M u c h o f
Practice Techniques
327

the research that helped establish key principles in cognitive restruc­

turing th erapy was glean ed from this tech niqu e. W ith o u t th e guided
te c h n iq u e th e therapist can never b e su re the client know s h o w to
c o u n te r m alad ap tive beliefs. W ith it, th e therapist can pin p oint and
correct a ran ge o f key p ro b lem areas.

Further In fo r m a tio n
A form o f g u id e d co u n te rin g called VC1 has b e e n discussed in five
p rev iou s w orks (Casey & M e M ullin, 1976; M e M ullin, 1986; M e Mullin,
Assafi, & C h ap m an , 1978; M e M u llin & Casey, 1975; and M e M ullin &
Giles, 1981). Leu n er (1969) has develo p ed a w h ole form o f psych other­
apy based o n guided imagery.
 Adjuncts

I n the pr evio u s eleven chapters w e h av e focu sed u p o n cogn itiv e

restructuring te c h n iq u e s th at therapists can use w ith m ost clients th ey
e n c o u n te r in their practice. This ch ap ter focuses o n specialized te c h ­
niqu es therapists can use with m o re limited clinical populations.
"Crisis C ognitive T ech niqu es" review s s o m e m e th o d s for h elp ing
clients w h o are in a crisis situ ation and don 't have tim e to learn m a n y
o f the b asic procedures. "Treating Seriou sly M e n ta lly 111 Patients"
show s the specialized tech n iq u es used with ch ro n ica lly psych otic
patients. "H andling Client Sab otage" discusses w o rk ing w ith resistive
clients w h o attem pt to u n d ercu t th eir ow n th era p e u tic grow th. "Cog­
nitive R estructuring Therapy with Addicted Clients" offers a n ew per­
spective o n co u n selin g clients w h o are drug or a lc o h o l d ep end ent.
Finally, w e finish the ch a p ter w ith tw o sections a im e d at h elp in g th e
therapist. T he first, "Cognitive Focusing," discusses a key principles
u nderlying all effective cogn itiv e tech n iqu es. T h e second , "C ore C o m ­
pon en ts o f CRT," gives therapists a checklist o f th e n ecessary a n d suf­
ficient co n d itio n s for th erap e u tic effectiveness.

C r is is C o g n it iv e T h e r a p y

Principles

Any m en tal health professional's im m e d ia te resp o n se to a client's

crisis situ ation is to ta k e w h a te v e r actio n seem s a p p ro p ria te to insure
th e client's physical and m ental w e ll-b e in g until his o r her c o n d itio n
stabilizes. T h en a n d o n ly then sh ou ld o th e r treatm en ts b e con sidered.
 Adjuncts

W e take a cogn itiv e ap p ro a ch to crises. T he goal o f this a p p ro a ch is

to discov er w h a t th o u g h t has p rov oked the critical state. If clients in
crisis h av e so m e b ack g ro u n d in cognitive techniques, an accelerated
form o f cogn itiv e th e ra p y can b e used to stabilize their con d ition at a
m o re c o m fo rta b le level. If the client is new to cogn itiv e therapy, c o u n ­
selors m ig h t try a m a ra th o n session o r resort to traditional crisis-in ter-
v e n tio n a p p ro a c h e s initially, th en in tro d u c e cognitive fu ndam entals
and te c h n iq u e s w h en stability h a s b e e n achieved.
Following are fou r cogn itiv e m e th o d s for h elp in g clients in crisis.

M eth o d 1. Quick P erceptu al Shift

To help y o u r client form a rapid perceptual shift, arran ge all o f the
necessary' c o m p o n e n ts.
1. C learly identify the core perception causing th e crisis. M a k e certain
th at th e client sees it clearly.
2. Point o u t th e perception that w ould re m o v e the crisis if th e client
believed it.
3. Do n o t red u ce th e client's ten sio n level to zero b y various a m elio­
rative procedures. S o m e red uction m a y b e necessary, b u t so m e neg­
ative e m o tio n s m a y m otiv ate clients to m ak e th e shifts.
4. Search for th e key bridge p ercep tions that can help carry clients
from th e old to th e n ew perceptions (see chap ter 9).The bridges
sh o u ld b e an image, value, o r b e lie f firmly im p lanted in the clients'
ex p erien ces. T hey shou ld have a strong positive em o tio n a l valence.
T h e bridges m u st c o m e from th e clients' exp erien ces since time
d o e s n ot allow for creating new ones.
5. C onfront all sidetracking the client m ay use to avoid the shift.
E x a m in e denials, alibis, excuses, sabotages, a n d evasions; press for
the shift. You m a y wish to refer to th e perceptual shift w ork sheet
(Table 7.1) as a guide.

M eth o d 2. M arathon Session

In a severe crisis, spend three o r four hours teaching you r client cog­
nitive m ethods. Take no m a jo r breaks. Flood th e client with coun ter­
ing tech n iq u es; rep eat them until the client co m p reh en d s their use. The
therapist sh o u ld dispute the key dam agin g beliefs causing the crisis,
c o n ce n tra tin g on the h e r e -a n d -n o w perceptions. Som etim es several
therapists m ay w ork with o n e client, increasing the persuasiveness o f
th e counters. As in o th e r crisis intervention techniques, the therapist
 Th e N e w H andbo o k of Cognitive T h er a py T echniq ues

presents an assured, se lf-co n fid en t m a n n e r to e n h a n c e th e client's feel

ings o f support. T h e therapist assu m es co n tro l o f th e session and
actively directs the client's responses.

M eth o d 3. B r ie f C ognitive R estru ctu rin g

Prepare a series o f q u estio n s fo r y o u r clien t to answer. Keep the
client focu sed o n the c o n te n t o f th e q u estions. Directly an d actively
in tervene to h elp y o u r client develop effective responses. For exam p le:

• W h a t are you feeling at this m o m en t?

• W h a t situ atio n are you in th a t su rrou n d s y o u r e m o tio n s?
• W h a t are you telling y o u rse lf in this situ ation th at is ca u sin g you to
feel upset?
• W h at o th e r thou ghts are co n n ec ted to this belief?
• Let's lo o k at each th ou g h t right n ow and m a k e a d ecision as to
w h eth er it is true o r false. Be tou gh a n d h a r d -n o s e d ly objective.
• If th e th o u g h t is true, w h at co n stru ctiv e steps c a n y o u ta k e right
now to change, avoid, o r c o p e w ith th e situation?
• If th e th o u g h t is false, w h a t is the key un tru th ?
• W hat ev id en ce d o y ou have against it?
• W h at are y o u r b est arg u m en ts for d ispu tin g th e th ou ght?
• W h at practical m e th o d can you use right n ow to help c o n v in c e
y o u rse lf o f the falseness o f y o u r thou ght?

M eth o d 4. Other C ognitively O riented

Crisis T echn iqu es
As in o th e r crisis interven tion m ethods, th e cogn itiv e therap ist m ust
im m ed iately intervene in an active, directive m a n n e r (G ree n sto n e &
Leviton, 1979, 1980, 1983; R osenblu h , 1974). Several CRT te c h n iq u e s can
b e adapted to this style.
1. Alternative attitudes and anticatastrophic thinking. S h o w clients less dis­
astrous alternatives to their fears.
2. Coping statements. G ive y o u r crisis clients a series o f se lf-statem en ts
th ey can use to c o p e with th e im m e d ia te crisis. For ex a m p le : "Dis­
tressing b u t n ot dangerous." "Ignore tryin g to solv e all y o u r p r o b ­
lems; ju st w ork o n this one." "Spoil y o u rse lf right now." "This is not
a q u estio n o f sickness or guilt; it is a m a tte r o f find ing a solution."
"I will solv e this ju st as I h av e solv ed th e o th e r crises in m y life."
Adjuncts 331

3. Label shift. C h a n g e negative labels like "bad," "sick," "nervou s b reak­

down," "going crazy" to n eu tra l o n es like "mistaken," "upset," "co n ­
fused."
4. R ational beliefs. Direct m u c h o f y o u r interven tion toward helping
clients form rational ju d g m en ts o f the crisis rather th a n correcting
irra tio n a l ones.
5. Objectifying. Help clients separate th e e m o tio n s th at are co n n ected to
th e crisis from the o b je c tiv e assessm ent o f the crisis.
6. Here and now. C o n cen trate o n present perceptions rather th a n their
historical roots.
7. Covert assertion. M ost clients b e h a v e passively in crisis. Teach them
h ow to solve their p ro b lem s assertively b y practicing assertive cop­
ing images.
8. Paradoxical methods. In crisis situations avoid the use o f paradoxical or
com p licated techniques. Clients are already confused, and such
te c h n iq u e s m a y b ew ild er th em more. Clients need procedures that
are direct, simple, a n d easy to rem em ber.

C om m en t
Crisis interven tion aim s at solving th e im m ed iate problem , not
rem o v in g all m alad ap tive cogn ition s and behaviors. T he therapist
sh ou ld w o rk o n ly with th e percep tion s that are exacerb atin g th e pres­
e n t situation. Later, after th e crisis is resolved, the therapist can work
o n the fu n d a m en tal co re beliefs that laid th e g ro u n d w o rk for th e cri­
sis.

F u rth er In fo r m a tio n
T h ere is o n ly o n e reference I will provide for this ch ap ter b ecau se
it is th e o n ly o n e th e read er will need. Frank Dattilio and A rthu r Free­
m a n have edited a n ex cellent b o o k a b o u t cognitive strategies in crisis
in terv e n tio n (Dattilio & Freem an, 1994). The b o o k describes th e the­
ory, research, and practice o f crisis in terven tion tech n iq u es for panic
disorders, suicide, depression, rape, child sexual abuse, natural disas­
ters, fam ilies in crisis, violen ce, and m a n y others. Each ch ap ter pro­
vides the read er with co p io u s references.
 T h f N fw H andbook of Co g nitive T herapy T echniq ues
332

T r e a t in g S e r io u s l y M en t a lly I I I P a t ie n t s

Principles

There are three basic m od es for using cognitive restructuring tech­

niques with chronically psychotic patients. I will briefly m en tio n th e first
two, and then spend the rem ainder o f the chapter discussing th e third.

S tre s s -re d u c tio n M odel

Various cognitive therapists assert th at critical life ev en ts in ter­
preted th rou g h m alad ap tive cogn itiv e sch em as p ro d u c e stress that, at
least in part, elicits psych otic episodes. A ccord ing to this theory, if
stress is reduced, the frequency, intensity, a n d d u ration o f patients
psychotic sy m p to m s will also b e reduced, ev en as th e biological c o m ­
p o n e n t rem ains u nchanged . T h e various m e th o d s th at th erap ists have
em p loyed to red uce patients' stress include: b e lie f m o d ific a tio n s to
d ecrease h allu cin atio n s a n d delusions; v e rb a l ch allen g es to help
patients co n tro l delusions; refocu sing te c h n iq u e s to h elp patients to
focus th eir attention toward o th e r ex tern al and intern al stim uli; re in ­
terpretation, w hich helps patients rein terp ret th eir psych otic ex p eri­
ences; cop in g skills, such as m od eling , resp o n se p rev en tion , and
th o u g h t-sto p p in g ; tea ch in g n o n d elu sio n al resp o n se s to cu e d social
situations; in creasing self-esteem , red ucing co ex istin g a n x ie ty and
depression, and teaching reality testing. S o m e o f th e se te c h n iq u e s
w ere develo p ed for neu rotic clients and h av e b e e n tran sp lan ted for
use w ith seriously m en tally ill patient.

R e h a b ilita tio n o f C ogn itive D eficits M od el

Cognitive and neuropsychological rehabilitation has recently b e c o m e
a target o f research. The tech n iqu es aim at helping patients learn skills
to reduce the cognitive deficits acco m p a n y in g their disorders. Specific
cognitive techniqu es have b e e n developed to im prove atten tion span,
concentration, psychom otor speed, cognitive flexibility, learning, c o n ­
cept form ation, auditory, cognitive sets, and memory. M a n y o f th e tech ­
niques were originally developed for b ra in -in ju re d persons, b u t they
have recently b e e n adapted for psychotic patients (Jacobs, 1993).

A cc e p ta n c e -in te g ra tio n M od el
T h e a c ce p ta n ce -in te g ra tio n m o d el em p h asiz es th e b io c h e m ic a l
basis o f psychosis, b u t it d o e s n o t assert th e d o m in a n t im p o rta n c e o f
e n v ir o n m e n ta l stresses, critical life events, o r co g n itiv e deficits. Psy-
Adjuncts___________ 333
/

ch o sis is con sid ered a brain disease th at needs to b e dealt with like
a n y other. T h e m od el su pports th e research com p iled over th e last 50
years su gg esting b io c h e m ic a l etiologies for c h ro n ic m ental illness. This
research e n c o m p a sse s g e n e tic origins suggested b y twin studies, a d op ­
tion studies, an d m o le cu la r biology. It also includes findings o n gross
b rain a b n o rm a lities, su ch as v en tricu lar enlargem ent, cereb ral asym ­
metry, soft n eu ro lo g ical signs caused by an in a d e q u ate intrauterine
e n v ir o n m e n t, and a b e r r a n t b io ch em ical pathw ays (Carson & Sanislow,
1993; M aher, 1988).
Im plicit in the acceptan ce-in teg ration m odel is that seriously m e n ­
tally ill (SMI) patients have n eu ro ch em ica l deficiencies, and that tradi­
tional cogn itive procedures developed prim arily for neurotic clients are
u nlikely to significant impact them. Cognitive interventions m ay b e o f
so m e help, b u t p sych otherapeu tic attem pts such as stress reduction,
delusions m odification, or cognitive skill training are unlikely to affect
patients' central problem s b eca u se th ey are essentially biochem ical.
Patient a cce p ta n ce is the key psychotherapeutic postulate o f the
m od el. Patients need to acknow ledge that they have a m a jo r b io ch em ­
ical disorder and to m ak e ad ju stm en ts in their lives to help them cope
with th e effects o f th e disorder. A c o m m o n nonpsychiatric exam ple
often giv en is p eople w h o have diabetes— they can live reasonably
norm al lives as lo n g as th ey accept that th ey h a v e diabetes, take insulin
as prescribed, and m ake ad ju stm ents in their diet and lifestyle. If dia­
betics d e n y h aving an illness they place them selves in severe danger.
Likewise, SM I patients need to accept that they have a m ental illness,
take psych otrop ic m edication, and m ak e ad ju stm en ts in their lives.
T he g rea ter th e b io n eu ro lo g ic a l disorder, the m ore SM I patients
n ee d to accept their condition. T he goal o f treatm en t is not ju st the
process v a ria b le o f reduced psychotic sy m p to m a to lo g y (as is often
tr u e in th e vu ln erab ility -stress m od el) but rath er the o u tc o m e goal o f
living in th e least restrictive e n v iro n m e n t possible. T he ideal o u tco m e
w o u ld b e for patients to successfully integrate b a ck into th e c o m m u ­
nity w ith o u t the co n sta n t n ee d for rehospitalization.

M eth o d
1. Ed ucate patients a b o u t their m en tal illness in a system atic, c o n ­
trolled fashion.
2. Aim to teach a cce p ta n ce rath er th a n red uce stress. Stress levels
sh ou ld n o t b e red uced to zero; s o m e stress provides a m otivation
to leave th e hospital.
 T h e N e w H andbook o f X o g nitive T h erapy Tec h n iq u es

3. W h e n th e patients are ready, give th em th eir d iag nosis an d tell

t h e m exactly w h y th e professionals w o rk in g w ith th e m have
m ad e th e diagnosis.
4. G ive each patient an 8 - 1 0 - p a g e m a n u a l w ritten specifically for
h im or h e r th at describes th e illness, th e p ossib le causes, and
specifically w h a t needs to b e d o n e to c o p e with it (see figure 12.1).
5. R equire patients to atten d ed u catio n classes o n m ed icatio n s, m e n ­
tal illness, a n d h ow to recognize and m a n a g e sy m p tom s.
6. Tell patients w h a t beliefs are co n d u civ e to b e in g released in to th e
c o m m u n ity and w h at attitudes are d a m a g in g an d w'ould keep
them in the hospital. Use a n y cogn itiv e ap p ro a ch e s th at will
im prove their ration ality (O levitch & Ellis, 1995).
7. Have patients w h o h av e accep ted th eir illness an d integrated into
th e com m unity' give testim on ials a b o u t h ow th e y lea rn e d to c o p e
w ith denial.
8. Do n o t co n fro n t patients' denial directly, b u t requ ire th em to learn
a b o u t m en tal illness (Milton, Patwa, & Hafner, 1978). Explain that
it is th e patients' jo b w hile in the hospital to learn a b o u t m en tal
illness and m ed icatio ns and th at th eir release fro m th e hospital
will b e in part d e p en d en t u p o n h ow w ell th ey learn th e m aterial.
9. Create a th era p e u tic c o m m u n ity w ith a "cognitive milieu," to help
e n h a n c e cognitive ch an ge (see W right, 1996; an d W right, Thase,
Beck, & Ludgate, 1993).
10. M a n y seriously m en ta lly ill patients will v e h e m e n tly reject a n y
su ggestion that th ey are m en ta lly ill. A n y direct attem p t to c h a n g e
this cogn ition results in a stro n g reaction— th e y m a y w a lk o u t o f
treatm en t, verbally attack, o r in so m e cases ev en p h y sically
assault th e therapist.

W e are e x p e rim en tin g w ith a te c h n iq u e th at uses grad u a ted sh ap ed

practice to red uce denial. W e sh ow th e patien t th e reversible a n d h id ­
den im ages illustrated in ch a p ter 9, presen ting th e m o n e at a tim e
from easiest to hardest, in grou p o r individu al sessions. T he p roced u re
usu ally takes several weeks. W e train patients to find th e hidden
im ages a n d reverse th e a m b ig u o u s drawings.
During these sessions w e m e n tio n n o th in g a b o u t m e n ta l illness or
psychotic sy m p to m s— w e sim ply teach patients h o w to see th e pic­
tures.
W e hyp oth esize that lea rn in g to see th e im ages m ay h elp patients
u ltim ately learn to see th eir illness b e c a u s e th e s a m e types o f tra n s­
form ation s are required. In b o th situations, patients m u st learn: (a) to
accept help from others, (b) n o t to give up looking, (c) to try sm all
Adjuncts 335

c h a n g e s first, (d) to practice hard, an d (e) to keep trying to lo o k at

things in a new way. O n c e they succeed with th e images, w e grad u ­
ally in tro d u c e t h e ir person al cogn ition s and teach them how to shift
th eir thoughts.
Figure 12.1 depicts th e first two pages o f a m a n u a l w e give to
patients w ith schizoaffective disorder to e d u ca te th em o n their m e n ­
tal illness.

What Is
To J o fin S ch izo affectiv e
fr o m y o u r T h e " S e h iz o " p a r t s ta n d s f o r S c h iz o p h r e n ia .

T rea tm en t Team
S o m e S y jn p t Q m g Q f S c h i z o p h re n ia
• T h o u g h t p a t t e r n s b e c o m e d is o r g a n iz e d a n d
illo g ic a l
■ T h e p e r s o n o f t e n e x p e r ie n c e s h a l lu c i n a ­
t io n s - - t h e y s e e o r h e a r th in g s t h a t n o b o d y

COPING e ls e s e e s o r h e a r s
• T h e s e n s e o f b o d y b o u n d a r ie s d e te r io r a te s
• E m o tio n s b e c o m e g r o s s ly in a p p r o p r ia te o r
fla t te n e d .
W IT H • T h e p e r s o n m a y h a v e d e lu s io n s - - b e lie v in g
In t h in g s t h a t n o b o d y e ls e b e lie v e s i n an d

SC H IZ O A FFE C T IV E t h a t a r e e it h e r r e a li s t i c a ll y im p o s s ib le o r
v e r y im p la u s ib le T h e r e a r e s e v e ra l ty p e s

D IS O R D E R G r a n d io s e = A n e x a g g e r a te d s e n s e o f o n e 's
im p o r t a n c e . p o - * e r . o r k n o w le d g e
F ^ rs e c u to rv = B e lie v in g t h a t a p e r s o n o r
g r o u p is c o n s p ir in g a g a in s t 5 0 u
S o m a n tlc = B e lie v in g th e r e is s o m e t h in g
w ro n g w ith jo u r
b o d y w h e n th e r e i s n 't
A n o s p g n o s ia = B e in g s u b je c t iv e ly c e r t a in t h a t
y iu d o n 't h a v e a m e n t a l h e a lt h p r o b le m . e \e n
t h o u g h jiO U h a w b e e n in a n d o u t o f m e n ta l
h o s p a ta ls f o r je a r s a n d e v e r y o n e a r o u n d you
( r e la tlw s . d o c to rs , fr ie n d s 1 k n o w t h a t j o u d o .

F I G U R E 1 2 .1 P a t ie n t m a n u a l

E x a m p les
Possibly th e b est ex am p le s o f th e beliefs o f seriously m entally ill
patients w h o have learned to accept th eir illnesses are the co m m e n ts
o f tw o patients— Kelly and R an d y (M e M ullin, Samford, & Kline, 1996).

KELLY: 1 was d iag n osed 15 years ago as h a v in g b ip o la r-II disorder

. . . Like m a n y professionals, I was very stu b b o rn . I did not want
to accept that I had, particularly, a seriou s problem . I den ied m y
actu al diagnosis o f m a n ic depression. I denied that for over a
year, u ntil it was b ey o n d m y control and I had to give in and be
o n e o f those people and take that medicine, w hich is called lithium
(her em phasis). . . . 1 w o u ld like the p u blic to realize that m ental
illness is an illness first a n d forem ost. It's like diabetes, h yp er­
tension, and like those illnesses, I have to take a m edication to
stabilize th e p ro b lem that's in h eren t in m y illness.
 I i i t N e w H andbook oi Co g nitive T h erapy T echniq ues

RANDY: I h a v e b e e n diagnosed w ith schizoaffective disord er and

I've b e e n u n d er doctors' care for o v er 3 0 years now. For m a n y
years I did n o t kn ow I was ill. I did n o t realize th at a n y th in g was
w ro n g w ith me. I ju st felt I was different, b u t it certain ly did n o t
feel g o o d b e in g th e way I was. . . . I did not like th e idea o f m e d ­
ication. It felt v ery u n co m fo rta b le for me, an d it to o k m e so m e
m o re years o f w an d erin g a ro u n d fro m place to p la ce to discover
th at I really did have a p ro b lem th at need ed s o m e m ed ical a tten ­
tion and also so m e psychotherapy.

C om m en t
Insight and a ccep tan ce are c o m p le x co n ce p ts an d c a n m e a n m a n y
things (Greenfeld, Strauss, Bowers, & M an d elk ern , 1989). But th e type
o f insight that allows seriously m en ta lly ill patients to live in th e c o m ­
m u n ity is so m e th in g specific. Interview s w ith patients w h o w ere a b le
to stay in th eir c o m m u n itie s revealed th a t their a c c e p ta n c e o f m e n ta l
illness consisted o f th ree parts: First, infernal— th e y b elie v ed th a t their
prob lem w'as b io ch em ical an d not ju st caused b y a b ad e n v ir o n m e n t
or b ad training. Second, global— th ey accep ted th a t th eir p ro b lem
en co m p a ssed m ost aspects o f their lives and was n o t ju st isolated to
o n e part. Third, stable— they k n e w that th e ir illness w o u ld n 't g o aw ay
in a few days, w eeks, or m o n th s an d that, b a rrin g a m ed ical b r e a k ­
through, they w ould h av e to c o p e w ith it for th e rest o f th eir lives.
M artin S elig m a n fo u n d that individuals w h o se a c ce p ta n ce includ ed
th ese th ree c o m p o n e n ts (internal, global, an d stable) w e re at a g rea ter
risk for depression, particularly learned h elp lessn ess (Seligm an, 1975,
1994, 1998). In his research th ese th re e factors w ere d am aging, b u t in
the present study th ey w e re helpful. W h y th e difference?
O n e answ er is that different types o f patients face different typ es o f
reality. Depressed patients often catastrophize their reality. T h ey d eny
having control over events that th ey really can control. As Seligm an and
his colleagues point out, internal, stable and global attribu tions induce
helplessness and contribu te to giving u p and not trying. T h e reality for
the depressed patient is quite different from that o f th e seriously m e n ­
tally ill patient, w h o often m inim izes th e extent o f his or h e r illness.
Seriously m entally ill patients have to face th e h arsh p resence o f their
ow n b ioch em ical disorder, w hich th ey can influ ence b u t not com pletely
control. T hey are faced with this reality th ro u g h o u t their life.
Similarly, th e a ttrib u tion style, w h ich is so help fu l fo r th e depressed
A d ju n c ts _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3 3 2

/
patient, can b e very d am a g in g to th e S M I patient. A ttributing their
m e n ta l illness to e n v ir o n m e n ta l factors (external) helps seriously m e n ­
tally ill patien t to b e lie v e th at all they have to d o is move, ch an g e their
jobs, o r get o u t o f the hospital to m ak e their psych otic sy m p tom s dis­
appear. Believing th at th eir hallu cin ation s and delusions are te m p o ­
rary (u nstable) p ro m p ts th em to refuse to take th eir m edications w h en
th e y leave th e hospital b e c a u s e th ey h o p e that their sy m p to m s will go
aw ay in a few days. B elievin g that their p rob lem is small (specific) may
keep th e ir se lf-e steem intact, b u t it also keeps th em from accepting
th a t th eir m e n ta l illness co m p e ls so m e m a jo r life adjustm ents.
T he exact n a tu re o f a cce p ta n ce cogn ition s is speculative, b u t it
ap p e ars th at th e core cen tral t h e m e is th e denial o f m en tal illness (see
fig ure 12.2). Since m ost hospitalized patients don 't b e lie v e th ey have
seriou s problem s, th ey see n o reason to take m edication. As o n e
p atien t said, "I'm n o t sick, so I d o n ’t need a n y pills." T hey generally

F IG U R E 1 2 .2 C o r e c o g n it io n s o f r e h o s p it a liz e d p s y c h o t ic p a t ie n t s
338 T he N l w H andbook oe Co g nitive T herapy T echniq ues

b la m e others— their families, t h e doctors,, the courts— to create an

ex p la n a tio n as to w h y th ey are in a psychiatric hospital: "T h e ju d g e
had it in for me"; "1 didn't d o a n y th in g w rong"; "I g o t a b u m rap." These
c ogn ition s keep their self-e steem u nrealistically high ("I m a k e a great
im p ression o n others, and I don 't h av e a n y faults") a n d feeds b a ck into
m a in ta in in g th e denial o f their m e n ta l illness ("W orthw hile p eople
aren't crazy").
In contrast, patients in th e c o m m u n ity a p p e a r to h av e accep ted
their illness. T hey b eliev e that they n ee d m ed ica tio n s to h elp th em
c o p e with their disorder. T h ey realize that they are re sp o n sib le for
b e in g in the hospital, usually b e c a u s e th ey stop p ed their m ed icatio n .
T hey h a v e g o o d self-esteem (I like m y self) b u t it's c o n d itio n a l— " If I
stop taking m y m ed icatio n I will b e c o m e a n o t - v e r y - n ic e p erson " (see
figure 6.5, p. 191).

F u rth er In fo r m a tio n

S tress R e d u ctio n M od el
M a n y stress red u c tio n therapists call th eir th e o r y the v u ln e ra b ility -
stress m odel (see Avison & Speechley, 1987; B irch w o o d & Tarrier, 1994;
Brenner, 1989; Chadwick, Birchw ood, & Trower, 1996; K in g d o n &
Turkington, 1991a, 1991b, 1994; Lukoff, Snyder, V entura, & N u e c h te r-
lein, 1984; N uechterlein & Dawson, 1984; N uechterlein, G oldstein, &
V entura 1989; Perris, 1988, 1989, 1992; Perris, N ordstrom , & Troeng,
1992; Perris & Skagerlind, 1994; Z ubin & Spring, 1977).

R e h a b ilita tio n o f C ogn itive D eficits

Neuropsychologists, o c cu p a tio n a l therapists, a n d reh a b ilita tio n sp e ­
cialists h a v e b e e n so m e o f th e m a jo r m ov ers in the use o f co g n itiv e
rehabilitation. S ee particularly th e jo u rn a l o f Clinical an d Experimental Neu­
ropsychology, Jou rn al o f Clinical Neuropsychology, Neuropsychological R ehabilita­
tion, and Cognitive Rehabilitation.
O n e o f the m ost im p o rtan t b o o k s in this area is H arvey Jacob s's text
Behavior Analysis Guidelines an d Brain Injury R ehabilitation (1993).
For m o re te c h n iq u e s see Bened ict (1989), Cassidy, Easton, Capelli,
Singer, and Bilodeau (1996), Jaeger, Berns, Tigner, an d D ou glas (1992),
Spaulding, Sullivan, Weiler, Reed, Richardson, and S torzb ach (1994),
Stuve, Erickson, an d Sp auld ing (1991).
Adjuncts_ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ — — — -— - - - - - - - - - - 319

A cc e p ta n c e -in te g ra tio n M odel

T h e e m p h a sis 1 give this m o d el co m es from research that colleagues
and 1 h av e d o n e with th e SM I p op u lation (see M e Mullin, 1998).
A lth ou gh I reco g n ize and accept th a t stress reduction and rehabilita­
tion o f cogn itiv e deficits can b e very helpful, I th in k that a m ajority o f
S M I patients could also b en efit from the a cce p ta n ce -in teg ra tio n
m odel.
A lthou gh m a n y o th e r cogn itiv e therapists h av e tended to ignore
this m od el, th ere have b e e n im p o rta n t exceptions. Hayes and W ilson
h av e created a new therapy, accep tan ce and c o m m itm e n t th erapy
(ACT), based on patients accep ting th eir illness and co m m ittin g to
c o p e w ith it. ACT suggests that em o tio n a l distress is caused by m al­
a d ap tiv e exp erien tial avoid an ce (Hayes, Strosahl, & W ilson, 1996;
Hayes & W ilso n , 1994).
M cG lash an (1994) a n d M cG lashan and Levy' (1977) discuss th e differ­
ences b etw een acute psychotic patients w h o "seal-over" (deny) and
those w h o integrate (assimilate) their psychotic experience. David (1990)
describes acceptan ce o f m ental illness in term s o f insight. He defines
insight as th e patients' ability to recognize that they are suffering from
a m ental illness and to reliably label their psychotic experiences in
term s o f th e illness. Coursey (1989) recom m end s that psychotherapy b e
given to patients so that they have accurate inform ation ab out the
causes and prognosis o f their disability. McEvoy, Apperson, et al. (1989)
and McEvoy, Freter, et al. (1989) explore the relationship betw een insight
and acute psychopathology. I h ey found that patients w h o had good
insight ab o u t their m en tal illness were significantly less likely to be
rehospitalized. Drury used an acceptance c o m p o n e n t in his study. Part
o f his cognitive therapy was to help patients, "T o face up to and inte­
grate their illness rather than seeking refuge in their psychotic experi­
en ces" (Drury, Birchwood, Cochrane, & M acmillan, 1996, p. 595). He
found that th e cognitive therapy group had fewer residual sym ptom s
after their acute psychotic episodes than the controls.
Possibly m ost p ro m in en t have b een the acceptance therapies.
A lthou gh originating from a behavioral rather than a cognitive frame
o f reference, acceptance and c o m m itm e n t therapy (Hayes, Strosahl, &
W ilson, 1996) suggests that psychological distress often results from
m alad aptive experiential avoid ance th at includes cognitive elements.
According to Wilson, Hayes, and Gifford (1997), psychopathology is in
part caused b y clients' efforts to reduce, escape, or avoid their problems.
M Q __________ _ ___ Th e N ew H andbook , o f Co g nitive I elerapy T echniq ues

H a n d l in g C l ie n t S a b o t a g es

Principles

Jam e s Randi, an in tern ation ally know n m ag ician and m ystic

debunker, offers to pay a s u m o f m o re th an o n e m illion dollars to any
person w h o ca n d e m o n stra te th e ex iste n c e o f p a ra n o rm a l pow ers
u n d er scientifically o b se rv a b le conditions. S in ce 1964 th o u sa n d s o f
person s have applied for the prize and several h u n d red h a v e m a d e it
throu g h th e initial screening; n o n e has sto o d up to scientific scru tin y
b y passing his scientific tests. R andi is still prepared to g iv e a c h e c k on
th e spot to a n y o n e w h o can c o n v in c e him o f p a ra n o rm a l capabilities
(Randi, 1982, 1989, 1995).
Randi describes th o se w h o h av e m ad e claim to his prize as falling
in to o n e o f tw o groups. First are th e ou trig ht fakes— th e sn a k e -o il
salesm en, th e flim flam artists. T hey kn ow th at th ey are fakes and h a v e
tried to win th e prize with sle ig h t-o f-h a n d tricks. S e c o n d are th e true
b elievers— a grou p far m ore interesting to therapists. T h ese p e o p le
actually b eliev e th at th ey h av e p ara n o rm a l pow ers and are am azed
w h en th e e x p e rim en t fails to prove it. M e m b e r s o f this se co n d grou p
suffer from w hat m ig h t b e called, "self-sabotage." T hey h a v e fooled
them selves so c o m p le te ly th at th e y b e lie v e th ey h av e pow ers that
they don't. M a n y clients b e lo n g to this se co n d group.
Paradoxically, se lf-sa b o ta g e clients are often very intelligent and
qu ite well educated b u t th ey s a b o ta g e the th era p e u tic process. I f o n e
is even m o d era tely o b je ctiv e it is silly to spen d tim e a n d m o n e y g o in g
to a therapist and then to su b tly u n d ercu t w h at the therap ist is trying
to do. Yet s o m e very bright p e o p le en g a g e in su ch b e h a v io r w h e n th ey
enter counseling. T hese clients don 't do th eir h o m e w o rk , m iss
appointm ents, o r use o th e r self-d efeating b eh av io rs. T hese sa b o tag e s
can b e distinguished from o th e r types o f client p ro b lem s o n ly in that
th ey m u st b e treated first, b e c a u s e n o progress will o c c u r if th e client
is en g agin g in sab o ta g e ; th e ability o f the client to resist g e ttin g help
is greater th a n th e ability o f th e therapist to help.
Clients m a y use various types o f sabotages:

• Secondary Gain. E n v iro n m en ta l rein fo rcem en ts a n c h o r the client's

beliefs. "It is easier n o t to change."
• Social Support. "People w o u ld n 't like m e if I changed."
• Value Contradiction. Not c h an g in g has a h ig h e r v a lu e in client's h ier­
archy. "It w ould b e w ro n g to change."
• Internal Consistency. T he old b e h a v io r is tied to so m a n y o th e r things
Adjuncts 341

th at c h an g in g it w ould requ ire c h a n g in g one's w h o le life. "It would

cost to o m u c h to change."
• Defense. "It w ould b e d a n g ero u s to change."
• Competitive. "I w o n 't let a n y b o d y tell m e w h at to do."
• Dependency. "If I c h a n g e 1 w o n 't need you anymore.''
• M agic Cure. "I sh o u ld n 't have to w o rk hard to change. It shou ld hap­
p en q u ick ly w ith o u t a great deal o f effort."
• M otivation. "I don 't feel I have to shift. I can b e h ap p y w ithou t
changing."
• Denial. "I u n d ersta n d ev eryth in g you are telling me." (They don't.)
"I will n ev er u n d erstan d a n y th in g you are telling me." (They will.)
• Behavioral Sabotages. Skipping sessions; argu ing against every princi­
ple presented; d o in g no w o rk in session b u t calling con stantly dur­
ing o ff h o u rs; n ot p ayin g fees; c o m p la in in g a b o u t n ot b ein g cured;
ju m p in g from o n e therapist to a n o th e r every tim e th ey reach an
a rd u o u s p h a se o f coun seling ; co m p lain in g a b o u t all the therapists
th e y h a v e seen b e fo r e y ou ; seein g you only in crisis an d discontin­
u in g th e m in u te th e crisis is over.

M eth o d 1. Counter S a b o ta g e
A fter you and you r clients h a v e develo p ed a list o f cou nters to an
irrational th ou ght, ask clients to w rite d ow n any sab otages o r argu­
m e n ts against th e co u n te rs that au to m atically o c cu r to them . Next
h a v e th em an alyze th ese sa b o tag e s and dispute a n d ch allen ge them
b e fo re th ey attack th e irrational th o u g h t (Giles, 1979; Loudis, personal
c o m m u n ic a tio n , April 10, 1979).

E x a m p le
Irrational Thought: "I can't let p e o p le know w h o I am. I need to hide
b e h in d a social m ask to protect myself."
Counter: "If I d o n 't sh ow w h o I am, n o o n e can ev er get close to me. I
will alw ays b e alone."
Sabotage: "But th ey m a y reject me."
Counter: "They are rejectin g m e now b ec a u se I am h idin g b e h in d a
ca rd b o ard m o c k u p o f myself!'
Sabotage: "B etter th ey don 't kn ow m e th en that they dislike me.
Counter: "B etter to give p e o p le a c h a n c e to like o r dislike m e than to
assu re th eir rejection b y play in g h id e -a n d -s e e k w ith myself:'
 T h e N e w H andbook oe Cognitive T h e r a j y T ech n iq u es

T he c o u n te r sa b o ta g e process is c o n tin u e d until clients can no

lon g er th in k o f a n y sa b o ta g e s to th eir counters.

M eth o d 2. Preventing S a b o ta g e s
It is far b etter to u n d ercu t sab o ta g e s b e fo re clients resort to them .
O n c e clients p resent their attitudes in public, th e y will d efen d th e m
against attack. I f it ap p ears to you that a clien t is likely to sa b o ta g e
therapy, in an early co u n selin g session h av e y o u r clients m a k e a list o f
all th e ways any person could sa b o ta g e counselin g . Ask th em to id en­
tify w h a t particular m e th o d th ey would use if th e y ev er decid ed to
sa b o ta g e counseling. Then discuss w h y th e s a b o ta g e w o u ld keep p eo­
ple from reach in g th eir th era p e u tic goals.
This te c h n iq u e is u su ally in trodu ced as follows:

O n e o f the things I h av e n oticed after c o u n s e lin g clients fo r 25

years is that m ost clients h av e m ixed feelings a b o u t therapy. Part
o f th em w an ts to im p rov e things in th eir lives an d for this rea­
son they c o m e to therapy. But a n o th e r part o f th em resists
c h a n g in g o r w orries a b o u t risking g ettin g in to a w o rse state th a n
they are in now. It's like th e y h av e tw o ta p e -re c o rd e d voices in
th eir brain, o n e sh o u tin g "Grow, ch ange, b e b e tte r ; w'hile the
o th er shouts, "Be careful! You m ay get w o rse; let it be."
I h av e also found that m ost clients h av e difficulty telling their
therapist ab o u t th ese con flictin g feelings, so th e y u su ally don't.
Instead, th ey su btly s a b o ta g e the therapy and o ften try to c o n ­
v in ce them selves that th ey aren't doing so.
I a m g o in g to give y ou s o m e ways o th ers h av e a ttem p ted to
sa b o ta g e counseling. I w ould like y ou to add s o m e m ore. If you
w ere g o in g to sa b o ta g e b u t you didn't w ant m e to kn ow it, w h a t
m e th o d s w ould you use?

S a b o ta g in g m ay b e m o r e w idespread th a n m ost th erap ists think.

G radu ate program s don 't often discuss it, a ssu m in g th at it is a rare
o ccu rren ce, b u t w h e n e v e r I h av e presented th e c o n ce p t o f s a b o ta g e to
m y clients a lm ost ev ery o n e se em s to k n o w ex a ctly w h a t I a m talkin g
about.

M eth o d 3. F inding P ay offs

List th e client's sab o ta g e s se p a ra te ly H yp oth esize w h at positive or
negative reinforcers (payoffs) are c o n n e c te d to th em . Discuss these
Adjuncts

payoffs w ith y o u r clients and help th em discover o th e r m e th o d s o f

getting th e payoff. H elp th e m d iscrim in ate b e tw e e n useful payoffs and
destructive ones.
T h eir sa b o ta g e th o u g h ts are like cogn itiv e tricks that they play
u p o n them selves. Beliefs su ch as, "1 could lose co n tro l and g o crazy,"
o r "1 m u st b e b e tte r th an all o th e r p e o p le to b e worthwhile," m ay not
b e solely m istak en percep tions arising o u t o f poorly synthesized
ex p erien ces. T hey m a y also reveal a kind o f cogn itiv e gam e that clients
play in ord er to reap se em in g rewards, ju st as a c o n artist plays tricks
o n th e p u b lic fo r ex tern al payoff, so clients m ay trick th em selves for
in tern al payoffs— to g e n era te feelings o f security o r high self-esteem ,
to red uce anxiety, to e m p o w e r s o m e o n e else, or sim ply to spice up an
oth e rw ise b o r in g existence.

M eth o d 4. E xposing th e P lay

O th e r clients m a k e co u n selin g a d ram atic play, a theatrical show, a
p e rfo rm a n c e in w h ich th e client is the p erform er and th e therapist is
th e au dien ce. Initially, clients m ay crea te th e dram a for external
applause, b u t after years o f practice they b eg in to play the role only
for them selves, long after ex tern al payoffs have vanished.
M a n y cognitive ap p roach es are n ot effective for clients w h o per­
fo r m for th e therapist, as they o ften view therapy as a n o th e r arena for
th eir p erfo rm an ce. W h ile th ese clients m ay pretend to work very hard
at th erapy th ey m a k e little if a n y real progress. So m etim es th ey reveal
th eir g a m e playing with an inapp ropriate sm ile or a verbal slip. S o m e ­
tim es th e y qu it co u n selin g alto g eth er w h en the sessions get serious.
To free th e client from a se lf-d elu sio n a ry belief, it is necessary to
e x p o s e their p e rfo rm a n ce as an act and th e n to redirect their focus on
th e p ro b lem rath er th a n the p erform ance. To d o this, look for the
in tern a l a n d ex tern al payoffs for th e theatrical performer. Identify
th ese to th e client, th en explain th e negative effects that en g agin g m a
p e rfo rm a n c e has on their ability to ach iev e th eir goals. Teach you r
clients m o re -p ro d u ctiv e, m ore-effectiv e ways to achieve th eir goals.

E x a m p le 1: The Story o f M ika

M o st clients are straightforw ard and visit cognitive therapists
b e c a u s e th ey w a n t help for p erson al problem s, b u t occasio n ally a per­
so n asks for help for d isin gen u ou s reasons.
A case in p oint o ccu rred with a w o m a n n am ed M ika from Sydney,
344------------------------------------ T h e N e w H andbook of Cognitive T herapy T e c h n iq u e s

Australia, w h o so u g h t o u t therapists sim ply^because sh e liked t o c o n ­

found them . Sh e w as in d e p en d en tly wealthy, h a d n 't w o rk ed for 15
years, and felt o v e rw h e lm in g ly bored. All s h e h ad to d o in life w as to
search a rou n d for s o m e th in g in teresting to do. S h e h a d b e e n th ro u g h
th e tennis, golf, and m a h jo n g class circuit, an d had tak en all form s o f
strange Eastern m editations.
Finally sh e stu m b led u p o n a n ew and m o re in teresting th in g to do.
Sh e would develop a weird, psychiatric a ilm e n t and g o to different
therapists preten d in g th at sh e n eed ed help. They, o f course, cou ld n 't
help h e r since s h e on ly m a d e up h e r problem , so sh e w o u ld leav e and
sadly say, I was so m u ch h o p in g th a t y ou could h elp me, b u t I see
y o u can't. O h my" T h e profession als felt upset; sh e felt triu m p h ant.
After a w hile, however, sh e had p erform ed h e r role so o ften th at sh e
c a m e to b e lie v e it. Sh e had learned to lie to herself, a n d h ad forgotten
that s h e had m ad e the w h ole thing up.
W h e n sh e c o n ta cted a therapist, h e r b e g in n in g m o v e w as alw ays
the same. Sh e called up in a terrified v o ice say ing s o m e th in g like,
"Doctor, you m u st help m e! You are a b so lu te ly th e o n ly p rofession al
in Sydney w h o could p ossibly gu ide m e th ro u g h m y h o rrib le p ro b ­
lem. I h a v e heard su ch great th in gs a b o u t you. I'm su re y o u 're th e on ly
o n e w h o is sm art e n o u g h to help. Please, please, m a k e s o m e r o o m in
y o u r b u sy schedule. I'm o n m y last legs. Please. I will bless you, G od
will bless you, and I'll pay w h atev er you ask."
Well, with a g a m b it so ex p ertly played, w h a t profession al could
resist? Few! S in ce therapists are as su b ject to fla tte n ' as th e n e x t p e r­
son, they usually said yes an d sw allow ed her hook.
Sh e th en played h e r first session artistically. S h e p resen ted a p ro b ­
lem akin to m u ltip le personalities, like the Three Paces o f Eve o r Sibyl. For
one session sh e w ould com e as N eurotic iVlika, acting scared,
depressed, confused, and passive. S h e cried, ru n g h e r h a n d s a n d said,
"O h my! O h my!" S h e sat w ith h er h e a d d ow n an d talked in a h ig h -
pitched w hine. T he next session s h e w o u ld w a lk in th e r o o m as M ika
the Vamp, w earing a slinky dress and discu ssin g in great detail her
sexual en co u n ters with rich and p ow erfu l m en. S h e so u n d e d su sp i­
ciously like Vivian Lee from Gone with the Wind. S h e ev en m a d e passes
at m ale doctors, w h ich they, fortunately, dropped.
Before th e m id d le sessions h e r therapists w ould eagerly an ticip ate
w h o m e v e r w ould sh o w up next, an d th e y w eren't d isappointed . M ika
w ould c o m e to th e sessions dressed as a fe m a le v e rsio n o f C o n a n the
Barbarian, speaking in short, gu ttural gru n ts and sprin k ling h e r c o m -
Adjuncts 345

merits w ith fo u r-le tte r words. T h e intent was ob v iou sly to sh o c k her
therapists, b u t the play was hard to carry' o ff since y o u r average psy­
ch ologist is not intim ately fam iliar with the d ialo gu e o f y o u r average
b arb a ria n . S h e did as b est s h e could, and a h eroic effort it was.
Eno u g h ! A lth ou gh therapists can b e fooled m a n y times b y clients,
th e ir gullibility is not eternal. Accordingly, o n e ex p erien ced psycholo­
gist had had it, a n d b e g a n to confron t h e r ab o u t h e r acting. He
p o in ted out that it was not n ic e to fool y o u r therapist. He told h er that
th e re are m a n y p eople with real problem s and that th ere aren t
e n o u g h psychologists, so if sh e really didn't m ind it w ould b e n ice if
s h e m a d e r o o m for s o m e o n e else. S h e stren u ou sly rejected his sug­
gestion, and m u sterin g th e c o m b in e d p ow er o f her various personal­
ities said: (N eurotic M ika) "I am m u c h to o n erv o u s to leave," or (Vamp
M ika) "Little old m e playing a g a m e? W hy, fiddle d ee dee," o r (Barbaric
M ika) "Fuck off! I pay; y o u listen!"
It w as clear th at th e psychologist w asn't replying th e way that her
o th e r therapists had. He hadn't g o n e o n TV exp lain in g th e fascinating
m u ltip le person alities o f M ika, o r rushed to publish h e r case m a pro­
fessional journal, p rob ed into the an cien t origins o f th ese different
p erson alities as s o m e others had done. He was a d isap p ointm en t to
her, a n d sh e was a b o u t to co n sid er finding a m ore appreciative audi­
ence, b u t th e psychologist decided to try o n e last approach b efore
e n d in g th e counseling . M a y b e h e could still parry h e r g am e and b e o f
so m e sm all help. It o ccu rred to h im that a paradoxical approach m ight
w ork, so h e searched for a te c h n iq u e that w ould catch h er o ff guard
a n d th at sh e w ould b e unprepared to parry.
He realized th at all o f h e r previous therapists had treated her the
s a m e way and sh e had gotten used to it. T hey had all assum ed that
sh e w as really o n e person w ith different personalities, and h a d all
rejected h e r c o n te n tio n that sh e was three different people. All o f them
h a d insisted th at e ith e r sh e was a deeply disturbed h u m a n b ein g w h o
had th ese m u ltip le personalities inside h e r or an actress out to> have
s o m e fun, w h ich was his view. Either way, all had rejected th e differ­
en t personalities as b e in g tru ly separate, w hile sh e pretended that she
was three different p eople and vigorously co u n te red a n y suggestion
to th e contrary. Sh e claim ed to h av e no recognition of th e o th e r per
sonalities, b u t h e w o n d ered w h at w ould h a p p e n if a therapist to o k her
at h e r w o rd an d pretended that each personality was in reality a dif
feren t person. ...
H avin g n o o th e r ideas, h e ch ose to treat her different personalities
346
T he N e w H andbo o k oi- Co g nitive T herapy T echniques

as sep arate people. He set up sep arate a c co u n ts for each o f th em , se p ­

arate psychological testing session s and se p a rate h o m e w o r k assign ­
ments. He gav e each p erso n ality different c o u n s e lin g a p p o in tm e n ts
and billed each separately. This cau sed h e r s o m e frustration, b e c a u s e
w h en sh e called u p as N eu rotic M ika to c h a n g e an a p p o in tm e n t m ad e
by V am p M ika th e psychologist said that a n o t h e r client h a d sched u led
(lie hour. Sh e b e c a m e even m o re an n o y ed w h e n as Vam p M ik a sh e
was given the sa m e ardu ou s 1 '/ ^ h o u r -lo n g psychological test that
N eurotic M ika h a d alread y taken. W h e n s h e hesitated to ta k e it again
th e psychologist asked, "W hat's th e difficulty? You h aven 't taken this
b efo re h av e y o u ? I know I've n ev er given it to you." S h e was taken
aback, b u t said, "No, o f cou rse not. It ju st lo o k s long."
During a session with o n e o f h e r characters h e w o u ld n 't let h e r refer
to things (hat o n ly th e o th e r p ersonality could know. This b e c a m e
increasingly m o re frustrating to M ika b e c a u s e s h e need ed to r e m e m ­
b e r m o re a n d m o re a b o u t w h a t each p erso n ality had told him . Finally
le gav e each p ersonality ex ten siv e h o m e w o rk th at w ould ta k e an
h o u r a day, and then at the next session h e w ould g o o v e r th e h o m e ­
w ork in great detail.
S o o n the b u rd en o f m a in ta in in g three ch aracters was to o m u c h for
Mika. S h e was ru n n in g o u t o f en erg y so s h e tried o n e final g am bit. Sh e
started to sw itch personalities in m idsession. It was a n ice try, b u t the
psychologist learned to c o u n te r it b y treating each c h a ra cter separately
w h en th ey pop ped up. He p re te n d ed th at each o n e h ad ju st arrived
and that the o th e r h ad n 't b e e n th ere at all. So w h en th e Vamp
appeared sh e was asked, "How was y o u r week?"— this after s h e had
ju st finished e x p la in in g h e r w eek in great detail as N eu rotic M ik a S h e
was forced to c o m e up with a w h ole n ew w e e k o f e x p e rie n ces to talk

T he w h o le th in g got to b e to o m u c h w o rk for M ika. At th eir last ses­

sion s h e vvasn t a n y particular personality, ju st M ik a w ith all (h e d if-
e re n t aspects that s h e really was anyw ay. W ith e v e r y b o d y there
tog eth er they could talk straight. T he psychologist told M ik a (hat life
n terestin g o n ly w h en w e are struggling against s o m e c h a lle n g e We
ca n n ev er b e ha p p y b y m ak in g up p h o n y ch allen g es an d p h o n y plots-
ere a ie e n o u g h real p rob lem s for h u m a n ity to w o rk o n w ith o u t c r e -
a ..n g cou n terfeit sham s. For exam p le, there's th e e n v ir o n m e n t
p ov erty injustice, AIDS, cancer, prejudice, addictions, p h y sical a b u s e ’
and all kinds o f things th a t n e e d s o m e real work. T h e psy ch ologist told
h er that s h e was bright, riel,, and had a great deal o f free time, and
Adjuncts 347
/

that s h e could m a k e so m e real differences in so m e o f th ese areas if she

put h e r tim e a n d en e rg y into them. He didn't call h e r on h er m ultiple
p erso n a lity gam bit, b u t sh e show ed h im s h e knew w h at h e was talk­
ing ab ou t. Sh e d id n ’t adm it to anything , b u t w h e n sh e left sh e ju st said
o n e word, "Thanks."
T h e last tim e th e psychologist saw M ika she was appearing on a
local TV station, speakin g on b e h a lf o f saving th e n o rth ern h airy-
nosed w o m b a t— o r so m e su ch creatu re that was in dang er o f losing its
habitat. All o f M ika's personalities w ere there fighting for the w om bat,
an d sh e seem ed happ y an d content.

E x a m p le 2 : The Story o f M au rice

The follow ing is an ed ited transcript o f th e o p e n in g session w ith M a u ­
rice, a very successful, attractive, divorced m an in his thirties w h o had
lots o f w o m e n interested in him. Unfortunately, M au rice also had a
history o f ru in ed relationships, all o f w hich end ed the sam e way—
w ith the w o m a n leaving him for a n o th e r man.

M A U R IC E: I am in th e sa m e situation that I have b e e n in m an y

tim es b efore. It's alw ays very painful a n d I need y o u r help. . . . I
am d oin g so m eth in g w ron g in m y relationships. I get involved in
a love relationsh ip and it goes real well for a while, but then
s o m e th in g starts h ap p en in g: I get jealous, I get suspicious, I get
m an ip ulative, I get angry', I get childlike, and I start sabotaging
th e relationship. It always en d s up the sa m e— the w om an gets
disgusted and I get real hurt and feel real inferior.
I h av e b e e n g o in g with a w o m an for a b o u t a year and a half
now. Sh e is a v ery attractive w o m a n — bright, vivacious, spirited.
S h e m ight b e b etter th a n me, socially m ore popular, m o re gre­
garious. M en h a v e always b e e n interested in her. I th in k I feel
inferior to her, a n d I a m scared. Sh e told m e recently that she
m ay b e b e g in n in g to feel love towards a n o th e r man. He is a
m a c h o type, rich, powerful, and has h ig h -sta tu s friends. I am not.
I am bright, creative, em o tio n a l— b u t I am not powerful.
I could feel the pain and hurt in m y gut w h en sh e said it. So
as I often d o in situ atio n s like this, I did a strange thing. I said,
"T h an k you for telling m e; 1 really ad m ire you r honesty. Clearly
th e re is o n ly o n e th in g to do in a situ ation like this. You m ust
p u rsu e th e o th e r relationsh ip as hard as you can, you should
348 T h e .N e w H an d bo o k of C o g n i t iv e T h e r a p y T e c h n iq u e s

sleep with h im ; spen d a lot o f tim e w ith h im and se e w h a t h a p ­

p en s to y o u r feelings towards him . S e e if you fall in love with
him . And then, if you are, th a t will b e it fo r us. I f y o u 're not, then
w e can g o alon g as w e were. I d o n 't w a n t to se e you until you
find out h ow you feel towards him." S h e protested, b u t I insisted
that sh e sh ou ld not see m e until sh e m a k es up h e r m ind . Sh e
said sh e loved m e and w asn't sure a b o u t h im an d w an ted to see
me. I said, "Well, m a y b e w e could, b u t w e cou ld n 't h av e a n y sex."
That's kind o f a typical e x a m p le o f th e p r o b le m I have. I d o th e
opp osite o f w hat I want. I say and d o things and I don 't kn ow
w h y I d o them . I keep d o in g things that g o c o n tra ry to w hat
w ould b e to m y advantage.

Even in th e first session th e client was b e g in n in g to se e th a t h e was

en g a g in g in so m e kind o f self-sab otage. Later sessions revealed w hat
this sa b o tag e was about.

M AURICE: I play this m artyr role w ith w o m en . T h ey hurt m e o r I

g et je alo u s b u t instead o f yelling at them , I trick them . I preten d
to b e kind, wise, forgiving, interested o n ly in th eir welfare. I sh ow
th em th a t I will sacrifice m y se lf for th eir h a p p in ess in true m a r­
tyr fashion.
The g a m e is really sickening. I say things like, "You g o ah ead
and m arry him. Be happy. I h o p e it w orks out. You are a w o n ­
derful person. I w an t to release you from me. I d o n 't w a n t to hold
you dow n anym ore.
It's totally bullshit. I don 't b e lie v e a w ord o f it. T h e p a y o ff I get
is twofold. First I get back at th e w o m a n for h u rtin g me. I m ak e
her feel guilty, and s h e can't attack m e b a ck for b e in g kind, car­
ing an d nice. Secondly, I fulfill m y little h e r o ic m a rty r im a g e o f
m y se lf by th in k in g w hat a terribly com p assion ate, kind, c o u r a ­
g eou s m a n I am.

It took M au rice m a n y m o re session s to c o n tin u e to ex p lo re th e

m artyr self-sab otage. At tim es h e w ould forget h e w as playing a role
and act like a m arty r again. But g rad u ally h e saw th e p e r fo r m a n c e and
its d am agin g effects. He practiced b e in g straight a b o u t his a n g e r and
started sh o w in g w h o h e really was— a n o rm a l h u m a n b e in g with
fears, angers, a n d jealousy, not a sacrificial la m b for m a n — or
w o m a n — kind.
Adjuncts 349

C om m en t
Clients will defen d their beliefs angrily if they feel attacked, so it is
b est to bu ild a g o o d clien t-th erap ist rapport b efo re ex p osin g se lf-sa b ­
o ta g e o r role-p laying . iMoreover, if th e therapist m istakes a real
re s p o n se for a d ram atic sham , m o re guilt and con fu sion will b e added
to th e client's already negative em otions.

Further In fo r m a tio n
T h e n a m e o f th e te c h n iq u e is taken from th e title o f Randi's (1982)
b o o k . Further readings in th e area will give therapists m ore tools to
d eal w ith excessiv e self-d ecep tio n in a variety o f areas (see Franklin,
1994; Gardner, 1957, 1981, 1991; Holton, 1995; Kurtz, 1992; Randi, 1989,
1995). Also se e th e w orks o f Carl Sagan— m ost relevant are: I h e Demon-
H aunted World: Science As a Candle in the Dark (Sagan, 1995) and Broca's
Brain: Reflections on the Rom ance o f Science (Sagan, 1979). O ne m agazine and
its parent organ ization devotes itself to ex p osin g flim -fla m — The Skep­
tical Inquirer: The M agazine fo r Science and Reason and The C om m ittee for
th e Scientific Investigation o f Claim o f th e Paranorm al, Buffalo, NY;
http://www.csicop.org.
Social psychologists and sociologists have ex am in e d social per­
form an ces, roles, an d presentations. S ee th e g e rm in a l w ork o f Erving
G o ffm an (1961, 1971, 1980, 1987).
O n e o f th e ways to distinguish th e b e g in n in g therapist from the
ex p e rie n c e d therapist is the latter's use o f paradoxical techniques.
R ay m o n d Corsini and M ilton Erickson, two highly ex p erien ced thera­
pists, use parad oxical m e th o d s ex tensiv ely (see Corsini, 1957, 1981,
1994, 1998). Corsini is the ed itor for the en cycloped ias o f psychology
(Corsini & Ozaki, 1984; Corsini & W edding, 1987). Erickson's w o rk can
b e fou n d in m a n y sou rces (Bandler & Grinder, 1996; Erickson, 1982;
Erickson & Rossi, 1981; Havens, 1985; Lankton, 1990; Lankton & Lank-
ton, 1985; Rossi, 1980; Rossi & Ryan, 1985).
350 The Ntw H andbook of C o g n i t i v e T h e r a p y T e c h n iq u e s

C o g n it iv e R e s t r u c t u r in g T h er a p y
w it h A d d ic t e d C l ie n t s

C o - a u t h o r e d w i t h P a t r i c i a G e i i l h a a r , D . P s y .,
S ydney, A u stra lia

P rin ciples
O u r b ra n d o f cognitive restructuring therapy m a k es a crucial dis­
tin ction b e tw e e n the treatm en t o f drug and alcohol a b u s e and the
treatm en t o f d e p e n d e n c y It views th e causes, cognition s, and m e th o d s
o f treatm en t for b o th as not o n ly different b u t in s o m e w ays qu ite
opposite. Clients w h o a b u se drugs (we includ e a lco h o l as a drug) can
b e treated with the standard cognitive tech n iq u es presented in this
and o th e r cogn itive th erap y b o o k s, b u t th o se w h o are seriou sly phys­
ically d ep en d en t require so m e m a jo r treatm en t ad ju stm ents.

D rug A buse
The typical m odel for clients w h o a b u s e ch em icals is n eg ativ e rein ­
forcem en t (see figure 12.3). T hey e x p e rie n ce a negative e m o tio n such
as anxiety, fear, depression, o r a n g e r and discover that th e se feelings
are reduced o r elim inated w h en they use drugs (escape conditioning).
After m a n y repetitions th ey learn th a t th e y o ften d o n 't e x p e rie n c e th e
e m o tio n if th ey take th e drug first (av oid an ce conditioning). C h em i­
cally a b u sin g clients o ften resort to drugs in resp o n se to life crises.
Drug a b u se m a y b e entirely learned. People are tau g h t to use e x c e s­
sively by m o d elin g o th ers in th eir early e n v ir o n m e n ts w h o se d ru g use
b e c a m e co n n ec ted to various external stimuli. T he drug a b u s e r often

Negative Emotion
A -----------------i

Avoidance Escape

Drug Use

F ig u r e 1 2 .3 N e g a tiv e r e in f o r c e m e n t m o d e l fo r a lc o h o l a n d d r u g a b u s e
Adjuncts 351

sh ow s p rem o rb id psychological disorders su ch as antisocial behavior,

p o o r im pu lse control, highly generalized anxiety o r depression, and
low frustration tolerance. Ih e y frequently h av e had a series o f critical
neg ativ e ev en ts (often sexu al or physical abuse) occu rrin g in child­
h o o d and adolescence.
The cogn itiv e c o m p o n e n ts o f the a b u se m od el consist o f two ele­
m ents. First, the initial co g n itio n s m ay elicit negative em otions. If the
therap ist c h a n g es th ese cognition s, the negative em o tio n s won't occu r
o r will o c c u r o n ly at a red uced level. Therefore, clients will have less
reason to esca p e o r avoid (Clarke & Saunders, 1988; Gallant, 1987). Sec­
ond, th e co g n itio n s m a y in terven e b etw e en th e stim ulus (critical en v i­
ro n m e n ta l event) (A) and th e resp on se (drug use) (Cb> Different
cogn itiv e therapists em p h a siz e different key cogn ition s for th e ch em i­
cal abuser. Ellis stresses low frustration toleran ce: "I can 't stand feeling
upset, and I m u st rem ove th ese feeling im m ediately b y drugs" (Ellis,
M cln ern ey , DiGiuseppe, & Yeager, 1988, a n d Ellis personal c o m m u n i­
cation, August 10, 1989). A aron Beck em phasizes lack o f coping skills:
"I don 't know h o w to h an dle this problem . If I take so m e drugs I can
forget ab o u t it” (Beck, W right, New man, & Liese, 1993).
D ru g -a b u sin g clients b en efit from cognitive th erap y (REBT, cogni­
tive restructuring, a n d cogn itive-b eh avioral). Unlike d e p en d en t clients,
th ey m a y learn to drink socially a n d m ay b e g o o d candidates for c o n -
tro lle d -u se programs.

D ru g D e p e n d en cy
Drug o r alcoh ol d e p e n d e n c y (figure 12.4) is an entirely different
m atter from drug abuse. Seriou sly ch em ically d e p en d en t clients do not
use drugs sim p ly to c o p e with negative em o tio n s o r stressful situa­
tions; th ey use drugs to rem o v e the begin n in gs o f w ithdrawal sy m p ­
tom s that their physical d e p en d en cy has produced.
T h ere is a strong physical c o m p o n e n t to clients' dependency. In i-

(Craving)

Physical Dependency

F IG U R E 1 2 .4 P h y s ic a l- d e p e n d e n c y m o d e l f o r d r u g a n d a lc o h o l a d d ic t io n
 T he N e w .H a n d b o o k qf C o g n i t iv e T h era py T e c h n iq u e s

tially, th e ir physiological sy stem

v s n eu tralize
v a n d e lim in a te a lc o h o l o r
drugs so th at th ey m ay recover quickly, b u t p ro lo n g ed use puts m ore
pressure o n their system s. As d e p e n d e n t clients c o n tin u e p u m p in g
alcohol o r drugs into th eir system, th eir various o rg a n s— particularly
their livers— spend m o re and m o re tim e trying to elim in a te th e drugs.
After th eir ph y siology b e c o m e s c o n tin u a lly overloaded, a n im p o r ­
tan t ev en t occurs. T h eir sy stem s stop treating th e drug as a foreign
su b sta n ce a n d start regarding the artificial ch em icals as natu ral s u b ­
stances n ecessary for hom eostasis. C h em ically addicted clients h a v e to
use m o re and m ore o f th e drug to return to a feeling o f norm alcy.
W h e n th e drug's p resen ce falls b elo w th e level th a t th e ir b o d ie s
d e m a n d th ey have to ta k e in m o re in ord er to return to h om eostasis.
As o n e addict told me, "It's as if m y b o d y gav e up fighting. W h ile ini­
tially it said, T a k e this drug away, I don 't w a n t it.' Later it told m e, 'I
give in! You w ant drugs? You can h av e th em ! But n ow you 're n o t o n ly
g o in g to w ant them, y o u 're g o in g to need them !'"
O n c e addicts b e c o m e physically d e p e n d e n t o n drugs, th e y can
n e v e r b e c o m e in depen dent. D ru g -d e p e n d e n t clients c a n n o t c h o o s e to
use socially; th ey can o n ly c h o o s e to stop. In ord er to c o p e w ith their
illness th e y m u st n o t u se at all. If th ey c o n tin u e to ta k e drugs, th e y will
find they can't use e n o u g h to b e satiated. T heir b o d ie s will crav e the
drugs m o re and more, an d th ey will n o lo n g er b e a b le to drin k o r use
for pleasure o r thrills, o r to rem o v e n eg ativ e em otio n s. T heir use will
h av e b e c o m e a physical co m p u lsio n driven b y th e h o p e that th e y can
te m p o ra rily lessen th e ir e v e r -w o r s e n in g w ith d raw al sy m p to m s.
Unless they stop, they m a y drin k or use drugs until th ey die.
Cognitive restructuring therapy, as o p p o se d to cogn itiv e th era p y in
general, hyp oth esizes a b im o d a l distribu tion for drug a n d a lco h o l
problem s (figure 12.5 and ta b le 12.1).
The left side o f th e distribu tion represents abusers. A busers often
are neurotic, h av e p rem orbid p ersonality disorders, little g e n e tic or
family history, few er cop in g skills, low self-esteem , an d low to le ra n c e
for frustration. A buse clients often ta k e drugs in o rd e r to relieve n eg­
ative e m o tio n s that they feel th ey can't c o p e with. T h ese clients can
o ften b e taught to co n tro l th eir drug use; cogn itiv e psychotherapy, as
w ell as o th e r psych otherapies, can help th ese clients c o p e w ith th eir
em o tio n a l p rob lem s w ithou t u sing drugs.
The right side o f th e distribution show s drug d ep end ency. T h ese
clients sh ow a stron g g e n etic predisposition a n d u su ally h a v e th re e or
m ore relatives with a sim ilar problem . T h ey p resen t a variety o f pre­
m orbid personalities, c o p in g skills, a n d frustration tolerances. D e p e n -
 Adjuncts

Abuse Dependent

QJ
cn
w
C
CD

a<u

F ig u r e 1 2 .5 B im o d a l d is tr ib u t io n o f a lc o h o l a n d d r u g a b u s e a n d a lc o h o l a n d
d ru g d e p e n d e n cy

d en t clients use drugs in a great variety o f trigger situations rather

th a n ju st w h en th ey are stressed; th e y sh ow gran d iose denial, m ay
h av e w ithd raw al sym ptom s, an d h av e a high toleran ce for their drug
o f choice. T h ey u su ally do not b en efit from traditional cognitive tech­
n iq u es b u t instead requ ire th e specialized cognitive therapy suggested
below.
If th e a b o v e analysis is correct it m ay a p p e a r that th ere is little the
cogn itiv e therapist can d o to help d e p en d en t clients. W h ile these

T a b l e 1 2 .1
Characteristics o f Abuse and Dependency

ABUSE DEPENDENCY
p r e m o r b id p e r s o n a lit y ----- ■ v a r ie d p r e m o r b i d p e r s o n a l i t y
la c k o f c o n c o r d a n c e g e n e t ic s - - - - - - - g e n e t ic p r e d is p o s it io n
n e u r o t ic h is t o r y - - - - - - - - - - - - 110 c o n s i s t e n t n e u r o t i c h is t o r y
a n t is o c ia l b e f o r e u s e - - - - - - - - - - - - - - - - - - - a n t is o c ia l a f t e r u s e
c a n le a r n c o n t r o lle d d r in k in g - - - - - - - - - - - - - - - - m u s t a b s ta in
f e w e r c o p in g s k ills - - - - - - - - - - - - - - - - - - v a r ie d c o p in g s k ills
lo w s e lf- e s te e m - - - - - - - - - - - - - - - - - - g r a n d io s e s e lf- e s te e m
lo w f r u s t r a t io n t o le r a n c e - - - - - - ■ v a r ie d f r u s t r a t i o n t o l e r a n c e
a v e r s iv e S j & C S p r e c e d in g u s e ■ v a r ie d S j & C S
n o s ig n ific a n t f a m ily h is t o r y --- s ig n ific a n t f a m ily h is t o r y
lo w t o le r a n c e f o r d r u g s - - - - - - - - - - - - - - - - - - h ig h t o le r a n c e
fe w w ith d r a w a l s y m p to m s ----- ■ m a n y w ith d r a w a l s y m p to m s
354 T he N ew H a n d bo o k op C o g n it iv e T h e r a p y T e c h n iq u e s

clients c a n n e v e r drink o r use flru gs in a con tro lled fashion, th ey ca n

stop the progression o f th e ir addiction. A lth ou gh th e y h av e failed
m a n y times, w ith help from th e therapist u sing a specialized cogn itiv e
restructuring treatm en t, th ey can stop.
Because the treatm ent o f a b u se is d escribed in a n u m b e r o f e x c e l­
lent pu b lication s (see Further Inform ation), w e will n ot rep eat th e p ro­
cedures here. Instead, w e will spen d th e rem a in d er o f this c h ap ter
discussing th e u n iq u e treatm en t required for ch em ical depend ency.
The a p p roach is called "cognitive confrontation," and it requires w o rk ­
ing on a totally different list o f cogn ition s th an m ost co g n itiv e th e ra ­
pists are in th e h ab it o f u sing w ith drug abusers.

A ssu m p tio n s fo r th e T re a tm e n t o f D ru g a n d A lcohol

D ep en d en cy
T he reaso n th a t addicts and alcoh olics are addicted to drugs is
physical, but th e rea so n that th ey tak e th e drug is psychological.
Addicts have learned to use and th ey can u n lea rn it. How? O b serv e
th e chart.

A --------------------------------------------------------► C
Craving U sing drugs o r a lco h o l

Before addicts use they have a craving fo r th e drug. T hey m ay b e

strongly aw are o f it o r th e y m ay n ot n o tice it at all, b u t it is there. T he
a lco h o lic craves alcoh ol so stron gly and th e h e ro in addict craves
h ero in so pow erfully b e c a u s e th e b o d y n o tices a d ro p in its usual level
o f the drug; th e addict feels th e pressure to get th e level b a ck to th e
a m o u n t they had b e e n taking. T he cravin gs also get stro n g e r w h e n
addicts e x p e rie n ce situations in w h ich th ey d ran k o r used in the past,
su ch as w h en they felt stress, w e re depressed, o r had relation sh ip or
e m p lo y m en t problem s. W h e n e v e r o n e o f th ese situ atio ns occurs, their
craving increases.
T he addicts' physical cravings are n o t th e so le c a u s e o f th eir p ro b ­
lem; it is n ot sim p ly an A ------- >> C th e o ry as p rev iou sly sh o w n . C rav­
ings a lo n e d o not e q u a l d ru g intake. Not all alco h o lics a n d addicts give
in to their cravings. T h ere are h u ndred s o f th o u sa n d s o f ch em ica lly
d ep en d en t clients a ro u n d the world w h o h a v e th e s a m e pow erful
cravings, th e s a m e frustrations, th e s a m e fights w ith th eir spouses, th e
s a m e jo b stresses. M a n y o f th e m h a v e sim ilar g e n e tic histories but
they don 't use w h en they feel th eir cravings. A visit to s o m e well
estab lished AA or NA m eetin gs will reveal m a n y c h e m ic a lly d e p e n d ­
 Adjuncts
355

en t p e o p le w ith 10 o r m o r e years o f sobriety w ho have felt th e crav­

ing h u n d red s o f tim es b u t h av e n 't picked up a drin k o r used a drug.
I cravings cause use and all addicts h av e the cravings, w h y don 't they
all use o r drink?
T he a n sw e r is that th e A --------► C th eo ry is wrong. There is a miss­
ing elem en t. T h e correct fo rm u la is:

A --------------------------- B ------------------------- C
C raving B elief Drug Use

As the form u la shows, it is th e B (w hat addicts and alcoholics say to

them selv es a b o u t th eir cravings) that causes th e m to use. T he B can
stand fo r m a n y things: their expectations ("I'll stop after a co u p le o f
beers"), th eir selected mem ories ("W hat great tim es 1 used to have in the
bar''), th eir self talk ("I n eed this to relax"), th eir excuses ("I really m eant
to stop"), denial ("I can m an ag e m y life perfectly well even th ou gh I use
cocaine"), overgeneralizations ("Because I was o n c e ab le to drink socially
[20 years ago], I still can"), fa lse predictions ("I know I can co n tro l m y
d rin k in g or dru gg ing in th e future") W h a tev e r they think, it is their
th o u g h ts a b o u t th eir cravings rather than th e cravings them selves that
c a u se th em to ta k e th e drink or use the drug.
O n e o f th e m a jo r attitudes that needs to b e changed is called the
stim u la tio n sy n d rom e. Addicts, alcoholics, an d o th e r p eople w h o have
ad d ictions (such as gam blers) h av e developed a love affair with e m o ­
tional extrem es. T heir addictions have caused them to spend m u ch o f
th eir lives o n an em o tio n a l roller coaster. T heir e m o tio n s have ranged
from ecstasy to despair, from gran d iose se lf-co n fid en ce to suicidal
d epression, from blissful c o n te n tm e n t to psychological terror. W ith all
th ese m o o d swings, a lcoholics and addicts have g otten used to "the
rush." W h e n th ey stop using, th e ir m o o d grad ually m oves toward n o r­
mal. This c a lm in g clown w ould b e a w onderful relief for th e rest o f us,
b u t to the recoverin g addict calm n ess is experien ced as a great em p ti­
ness. Life se em s b o rin g and flat. Since th ey h a v e sp en t m u ch o f their
lives in th e pursuit o f exaggerated em otio n s, th ey have a strong vis­
ceral d iscom fort with h a r m o n y and em o tio n a l balance. This attitude
can b e a m a jo r b arrier in th eir recovery.
For exam p le, an alc o h o lic client n a m e d Nigel had a pattern o f goin g
o n an d o ff th e w agon. He w ould attend alcohol treatm ent programs,
g et s o b e r fo r 6 m o n th s, im p rov e his relationships, a n d start working
again. W ith all aspects o f his life ru n n in g sm oothly, he would start
integrating d is h a rm o n y b y picking fights with his wife, com m itting
 T he N ew H an dbook of C o g n i t iv e T h e r a p y T e c h n iq u e s

p etty crim es that got him in tro u b le with the law, and sh o w in g up late
for work, th us putting his jo b in jeopardy. Finally h e w o u ld end up
d rin king again, b la m in g his relapse o n all o f the tr o u b le h e w as in.
W h y did h e b o t h e r g o in g th ro u g h this w h o le charade?
He m ay h av e sim p ly w an ted to drin k again an d created all o f his
troubles to give him an excuse. But a n o th e r reason is th e stim u la tio n
syndrom e. A lifetim e o f u sing and d rin k in g caused Nigel to get used
to a d ram atic lifestyle o f em o tio n a l highs and lows, a c h r o n ic cycle o f
crisis situations. He felt that h e w as o n ly h a lf alive u nless h e was
struggling with o n e em o tio n a l crisis o r another. N orm al em o tio n a l
feelings were u n a ccep ta b le to him ; h e felt h e w as b e in g e m o tio n a lly
deprived. He created p rob lem s to stir his life u p again so h e could feel
"the rush."
Nigel's attitude was th e real culprit. He believed that life w as su p ­
posed to b e a series o f triu m p h s and tragedies, an d w h en th ese
stopped b ec a u se o f his recovery h e felt h e had to liven things up
again. This b e lie f led to his relapse.
Since addicts' beliefs p ro d u ce th eir drug use, th ey h a v e to ch a n g e
their th ou g h ts in ord er to b eg in their recover)'. No m a tter h ow strong
their cravings, a lcoholics and addicts don't have to use.

M eth od
1. D e te rm in e w h e th e r you r client ab u ses drugs o r is d e p e n d e n t o n
them . There are m a n y possible ways to m a k e this decision. There
are standard sc ree n in g tests, su ch as th e MAST, CAGE, DQEAA and
SADQ, b u t th ey all suffer from the s a m e lim itation o f all p a p e r -a n d -
pencil tests have— the lack o f c a n d o r in clients' responses.

T h e Langton test (figure 12.6) increases a ccu ra cy b e c a u s e it is b ased

o n a structured interview th at allows the c o u n s e lo r to a sk detailed fo l-
lo w -u p questions. T he test is given orally to clients an d scored b y th e
exam iner. It can b e given in grou p s o r individually.
T h e Langton test is based o n the DSM -III, DSM-IU-R, DSM-1V a n d has
tw o c o lu m n s and four sections. For a diagnosis o f d e p e n d e n c y to be
m ad e th e client m u st sco re in b o th colum ns.
Scoring. T he total n u m b e r o f ch eck m ark s are added for each c o lu m n
and su m m e d into a gran d total. N u m b e r o f D U ls a n d fam ily m e m b e r s
with addiction p rob lem s are added to the score.
Results. T he m e a n g ra n d total for d e p e n d e n t clients is X = 27.59; SD
= 6.54; N - 321 (cross-cu ltu ral sa m p le from Australia, W ash in g to n
 Adjuncts
357

N am e:
D a te :

Langton Test
U SE
TO LERA N CE
Q W eight problems, ulcer
M.D. told you to cut down
Q Daily use
O Binges lasting 2+ days Q Tolerance
Q Could not control
Q Blackouts
Q Failed to stop (Need for marked increase
Q Early opener in amount of drug to get effect)
Q Other illnesses because of use

S O C IA L AN D W O R K W IT H D R A W A L S
Q Off work
Tremors
Q Driving accidents Q Nausea & vomiting
r l
L J Other accidents Q Malaise
□ Arrested in public places Q Tachycardia, sweating, + BP
1— L
L J Arguments at home Q Anxiety
Q Violence— assaults, damage Q Depression
Q DUIs
L D Rage
Q Lost job Q Headaches
Q Divorced or separated [^ Swelling— skin, face, legs
Q M oney worries Q Night terrors
Q Injuries Q Delirium
Q No. of family members addicted Q Dementia
O Hallucinations
Delusions

Total = Total =

F i g u r e 12.6 T h e L a n g t o n T e st f o r s e v e r e a l c o h o l a n d d r u g d e p e n d e n c y a n d
s c o r in g a n d in te rp re ta tio n p ro ce d u re s

State, and Hawaii). In th e su b categ ories the m ean n u m b e r o f checked

item s for patients are as follows: Pathological use— X = 8.27; SD = 2.24.
Im p aired So cial o r W ork Fu nctioning— X = 8.59; SD = 2.61. Tolerance
= 98%. W ithdraw al Sy m p tom s— X = 7.86; SD = 5.49.
Interpretation. A sco re o f 10 o r less clearly puts clients into the abuse
category, sin ce less th a n 2 % o f d e p en d en t clients would achieve such
a result (usually o n ly y o u n g d e p en d en t clients b eg in n in g their drug
use). A ch em ical ab u sin g client usually reports o n e family m e m b e r
with an ad d iction problem , w h ile a d e p en d en t client reports a m ean
3.5.8 T he N ew H a n d bo o k oe C o g n it iv e .T h e r a p y T e c h n i q u e s

o f 5.03 (but th e re is a large standard deviation, SD = 4.83). No m atter

w h a t th e overall score, th e client needs to present so m e signs o f toler­
an ce o r w ithdraw al sy m p to m s (co lu m n 2) in o rd e r to a c h ie v e a d iag­
nosis o f dependency.
Eighty-six percent o f th e alc o h o lic patients in the sa m p le rep orted
b lack outs; 6 8 % w ere separated or d iv orced b e c a u s e o f th eir d rinkin g;
6 3 % h a d b e e n charged with driving w h ile intoxicated ; 4 5 % had b e e n
arrested for v io le n t o r assaultive b e h a v io r w h en drunk.
W e found th at o n e o f the m a jo r d iscrim in ation q u e s tio n s is th e
clients' ability to co n tro l th eir drug use. S u b je cts w ere asked, "How
m a n y tim es were you ab le to lim it y o u r intake o f drugs or alcoh ol
w h en you tried to con trol y o u r use?" T h e a b u s e r client stated they
could co n tro l th eir intake 98/100 w h ile th e d e p en d en t patient could
o n ly r e m e m b e r o n e tim e o u t o f ev ery 558. M a n y o f th e d e p e n d e n t
clients said th ey had n ev er b o th e re d to try to limit th eir in take at all.

2. I f y o u r client scores in th e d e p e n d e n t category, find th e Bs that

m ain tain this dependency.

Before y ou can c h a n g e clients' th o u g h ts a b o u t drugs o r a lco h o l y ou

need to have an accu rate list o f th e core beliefs th at m ay b e in tim ately
related to th eir use. After trying several lists w e h av e d iscov ered th e
following 42 beliefs to b e m ost revealing; m u c h o f th e th era p y w e do
with ch em ically d e p en d en t clients is based on c h an g in g th e se 42
beliefs. W e discovered th ese co g n itio n s by using th e follow ing p ro c e ­
dures.
M ethod. A large list o f alcoholics' and addicts' se lf-sta te m e n ts was
com p iled b y therapists w ith ex ten siv e clinical e x p e rie n c e w ith c h e m ­
ical addiction. Each statem en t was co n v erte d to a stro n g ly -a g re e to
stron gly -d isagree Likert scale. T he statem en ts w ere th e n giv en to tw o
large sa m p le grou ps o f ch em ica lly d e p e n d e n t clients. T h e first sam p le
com prised clients w h o w'ere still d rin k in g or u sing (N — 285). T h e sec­
ond sam p le in clu d ed clients w h o w ere at various stages o f their recov­
ery, ranging from im m ediate, posttreatm ent, to o v e r 10 years (N = 230).
Results. Forty-tw o beliefs distinguished th e u sin g from the recover­
ing grou p o f clients. T h ese w ere in co rp o ra ted in to th e M e M u llin -
G eh lh a ar Addiction Attitude test (MGAA) (tab le 12.2). (The test is used
for ch em ically d e p en d en t clients only. It cannot b e used fo r clients w h o
a b u se drugs o r a lco h o l b e c a u s e the ap p rop riate answ ers w o u ld b e dif­
ferent for this population.)
Administration. It can b e giv en in grou p s o r individually. T h e MGAA
is read to th e clients, th e item s are explained, and a n y q u estio n s are
 Adjuncts
359

T a b l e 1 2 .2
M e M ullin-G ehlhaar Addiction Attitude Test (MGAA)

C I R C L E W H AT Y O U B E LI EV E

1. I am not responsible for my drinking or drugging.

S tr o n g ly A g r ee A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

2. I can stop using through willpower alone.

S tr o n g ly A g r ee A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

3. A couple of drinks are good for me.

S tr o n g ly A g r e e A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

4. I can't stop, so why bother?

S tr o n g ly A g r e e A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

5. A little bit can't hurt me.

S tr o n g ly A g r e e A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

6. I need to use to have fun.

S tr o n g ly A g r ee A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

7. It's normal to use the amount I have used in the past.

S tr o n g ly A g r e e A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

8. Bad feelings (fear, sadness, anger, etc.) cause me to use too much.
S tr o n g ly A g r e e A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

9. The best way to stop feeling bad is to use.

S tr o n g ly A g r e e A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

10. Being high or drunk feels good.

S tr o n g ly A g r ee A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

11. I can handle my drugs better than others can.

S tr o n g ly A g r e e A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

12. I need the drug or drink to feel more self-confident.

S tr o n g ly A g r ee A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e

13. Drugs are a good way to remove boredom.

S tr o n g ly A g r ee A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

14. I can cure my drug problem with a little self-discipline.

S tr o n g ly A g r e e A g ree N eu tra l D is a g r e e S t r o n g ly D is a g r e e
360 T h e N ew H an d bo ok, of C o g n it iv e T h e r a p y T e c h n i q u e s .

T a b l e i ? .2 (C o n t in u e d )
M e M ullin-G ehlhaar Addiction Altitude Test (MGAA)

15. 1 can control my use if I try hard enough.

Strongly Agree Agree Neutral Disagree Strongly Disagree

16. It's my fault that I am addicted.

Strongly Agree Agree Neutral Disagree Strongly Disagree

17. Something inside of me takes over and makes me use chemicals.

Strongly Agree Agree Neutral Disagree Strongly Disagree

18. Addiction is just a bad habit.

Strongly Agree Agree Neutral Disagree Strongly Disagree

19. Outside catastrophes (losing a job, spouse leaving, being in a hospital) cause
people to use drugs or to drink too much.
Strongly Agree Agree Neutral Disagree Strongly Disagree

20. I can cope better with life by using chemicals.

Strongly Agree Agree Neutral Disagree Strongly Disagree

21. Using drugs or drinking is a good way to get back at someone.

Strongly Agree Agree Neutral Disagree Strongly Disagree

22. I have to give in to my craving.

Strongly Agree Agree Neutral Disagree Strongly Disagree

25. You can be cured of addiction.

Strongly Agree Agree Neutral Disagree Strongly Disagree

24. The best way to stop withdrawal symptoms is to take more drugs.
Strongly Agree Agree Neutral Disagree Strongly Disagree

25. M y drug problem or my drinking problem is not that serious.

Strongly Agree Agree Neutral Disagree Strongly Disagree

26. I can always predict that 1won't lose control over myself when I use.
Strongly Agree Agree Neutral Disagree Strongly Disagree

27. I am a better lover when I am drunk or high.

Strongly Agree Agree Neutral Disagree Strongly Disagree

28. Social pressure made me drink or use too much.

Strongly Agree Agree Neutral Disagree Strongly Disagree

29. I need a drug or a drink to keep my emotions from overpowering me.

Strongly AgreeAgree * Neutral Disagree Strongly Disagree
Adjuncts 361

T a b l e 1 2 .2 ( C o n t in u e d )
M e M ullin-G ehlhaar Addiction Attitude Test (MG A A)

30. I c a n re c o v e r w ith o u t h elp if I try h a rd e n o u g h .

S tro n g ly A g ree A gree N eu tral D is a g r e e S t r o n g l y D is a g r e e

51. I n e e d a d r i n k o r a d r u g t o fe e l b e tte r.

S tr o n g ly A g ree A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

52. A p e r s o n w h o w o r k s h a r d e a r n s s o m e d r u g s o r a f e w d r in k s .
S tr o n g ly A g ree A gree N eu tral D is a g r e e S t r o n g l y D is a g r e e

55. U s i n g c h e m i c a l s is a g o o d w a y to e s c a p e f r o m life's s tre s se s.

S tro n g ly A g ree A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

54. I s h o u l d b e h a p p y a ll t h e t im e .

S tr o n g ly A g ree A gree N eu tral D is a g r e e S t r o n g l y D is a g r e e

35. I am n o t a n a d d ict o r a n a lco h o lic.

S tro n g ly A g ree A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

36 . Y o u c a n 't te ll m e a n y t h i n g a b o u t m y a d d i c t i o n th a t I d o n 't k n o w .

S tr o n g ly A g ree A gree N eu tral D is a g r e e S t r o n g l y D is a g r e e

37. W e s h o u l d g e t w h a t w e w a n t in life.

S tro n g ly A g ree A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

38. B e i n g d r u n k o r h i g h u n c o v e r s a n in d i v i d u a l 's r e a l p e r s o n a lity .

S tr o n g ly A g ree A g ree N eu tral D is a g r e e S t r o n g ly D is a g r e e

59. P s y c h o l o g i c a l p r o b l e m s c a u s e a d d ic t io n .

S tr o n g ly A g ree A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

40. T h e b e s t w a y t o h a n d l e p r o b l e m s is n o t t o t h i n k a b o u t t h e m .

S tro n g ly A g ree A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

41. 1 a m m o r e c r e a t i v e w h e n I u s e o r d rin k .

S tro n g ly A g ree A gree N eu tra l D is a g r e e S t r o n g l y D is a g r e e

42. T h e r e a r e m o r e i m p o r t a n t t h i n g s in life t o w o r k o n t h a n m y a d d ic t io n .

S tr o n g ly A g r e e A gree N eu tral D is a g r e e S t r o n g ly D is a g r e e

© 1990 R ian E. M e M ullin

 T u t N e w H a n d bo o k of C o g n i t iv e T h e r a p y T e c h n iq u e s

answ ered. Clients have the item s in front ofvthem a n d circle o n e o f the
five ratings after e a c h item.
Scoring. Five points are given for "Strongly Agree" an d o n e p o in t for
"Strongly Disagree." U n m a rk ed item s are scored as "Neutral" an d are
w orth th ree points. M e a n score for n o n recovering, a lco h o l an d d ru g -
d ep en d en t clients is X = 110.5; SD = 16.6. R ecovering clients' scores
varied d e p en d in g u p o n the len g th o f their recover)' (see figure 12.7).
The therapists can translate the raw scores into p ercentiles u sing the
m e a n and standard deviation.
Interpretation. It's im p o rta n t to realize that th e n o r m g ro u p o f th e
MGAA is clinical. A score o f 110 places th e client at th e 5 0 th p ercen tile
o f ch ro n ic d ru g - and a lc o h o l-d e p e n d e n t clients. O f all drug an d a lc o ­
hol clients this grou p can b e con sid ered th e m ost severe (Jellinek's
g a m m a category, Jellinek, 1960). T h e average client in this g ro u p has
b e e n using drugs for m a n y years, show s severe w ithdraw al sym ptom s,
has n u m e ro u s legal problem s, and has a ttem p ted an d failed in m a n y
previous drug treatm ent program s. T h e h ig h e r th e sco re th e m ore
dam agin g the client's attitudes and th e farth er aw ay from recovery the
client is. T h e therapist can use th e MGAA to d e te rm in e h o w far a client
has progressed in recovery' (figure 12.7) b y c o m p a rin g th e individual
score to th e m e a n o f clients at different stages.

5. G o over the M G A A test results w ith y o u r clien t and ex p la in the

co re factors that keep clients d rin k in g o r using (see fig ure 5.4, p. 87
fo r a grap h ic rep resen tation o f th ese factors).

Five factors h av e b e e n ab stracted from the test. W h e n I explain

them to clients I simplify th e ex p la n a tio n b y d raw in g an a n im a l th a t
describes each factor. I tell clients, "Let's see w h at ty p e o f a n im a l you
are telling y o u rse lf th a t keeps you drinking/using." (Look at th e test.)
"Ah yes. You are a fox."

F a cto r 1. T he Fox
I can co n tro l m y drinkin g or drugging a n y tim e I wish. I h a v e
w illpow er over it. I can d o it-on m y o w n w ith o u t help. ("I a m clever
like a fox.")

F a c to r 2 . T he L am b
I am not resp on sib le for m y use. T h e devil m a d e m e d o it. O thers
are to b lam e. It's p o o r potty training. ("I am help less as a lamb.")
Adjuncts 363

I 1 0.7

Length of Sobriety

Pre = immediately before beginning drug treatment.

Mid = halfway through inpatient drug treatment.
Post = immediately following inpatient treatment.

One year to 10+= years of sobriety based on the client's

anniversary date. Please note that the lowest possible score
on the MGAA test is 42.

F IG U R E The mean M GAA scores for chronic drug- and alcohol-depend-

1 2 .7
ent clients at different times during their recovery

F a c to r 3. T h e Pig
It still feels g o o d to use. I still like it. I am m ore creative.

F a c to r 4 . T h e O strich
M y use is n ot a big problem . It doesn't really h u rt me. Nothing to
w o rry about.

F a c to r 5. T h e B u tterfly
I need th e drug to m a k e m e feel better. I ca n 't c o p e with life with­
o u t it. ("I am fragile like a butterfly")

4. Use variou s cogn itiv e th erapy tech n iq u es to help clients change

t h e ir m alad ap tive beliefs. Focus particularly o n the items o n the
MGAA that clients strongly agreed with.

G rou p sessions and th era p e u tic classes that describe w h y the beliefs
are false are g e n erally m o re effective th a n individual sessions. In addi­
tion, use m a n u a ls and pam p h lets that discuss w h y th e 42 beliefs are
false (see particularly M e M u llin & Gehlhaar, 1990a). In ou tpatient
 T u t N ew H a n d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s
364

grou p s provide a m ix o f clients (som e b e g in n in g recov ery and so m e

w ith a y e a r o r m o re o f sobriety). T h e m o re ex p e rie n c e d clients can
m od el h ow to dispute so m e o f th e thoughts. R equire AA an d NA
m eetin gs b e c a u s e th ese organ ization s dispute sim ila r beliefs.

E x a m p le 1. Client M a n u a l*
Beliefs
1. I am n o t resp on sib le for m y drinkin g or drugging
17. S o m e th in g inside o f m e takes o v e r a n d m akes m e use chem icals.

E x a m p le
Ian, o n e o f o u r clients, heard o u r talk a b o u t drug add iction b e in g a
b io ch e m ic a l p rob lem th a t h e had p ro b a b ly inherited. He w e n t h o m e
and told his wife th a t sh e was w ro n g to b la m e h im for using, sin c e it
wasn't his fault in the first place.

C o u n te r
Your d e p e n d e n c y o n drugs is physical, b u t y o u r actu al use is not.
Taking a drink o r a drug is a v o lu n ta ry b eh avior. N oth ing inside or
outside o f you m akes you drink. You d o it! You g o in to th e pu b , sit on
the b a r stool, lo o k at th e selection, o rd e r a drink, pay th e bartender,
lift up th e glass, b rin g it to you r lips, an d sw allow it. No craving, reflex,
com p u lsion , em otio n , conditioning, disease, o r o th e r factor m a k e s you
en g age in this c o m p le x behavior. All o f th e se things m a y in clin e y o u
to drink, b u t u ltim ately it is you saying "yes" th a t starts th e process.
The devil doesn't m a k e you d o it. You are resp on sib le! O n ly you can
stop!

Beliefs
3. A co u p le o f drinks are g o o d for me.
5. A little bit ca n 't h u rl me.

E x a m p le
In o n e o f o u r grou p s a client n am ed Ted said th a t a d o c to r h ad told
him th at so m e a lco h o l was g o o d for people. T he d o c to r th o u g h t a
co u p le o f glasses w ould h elp h im relax an d thin his b lo o d , m ak in g

*The following excepts are based on a manual we hand out to our addicted
patients. (Me Mullin & Gehlhaar, 1990a). Reprinted with permission of the
authors. *
Adjuncts 365

him less likely to develop h a rd e n in g o f th e arteries.

A lth o u g h l e d w asn't in the h ab it o f listening to m edical advice, he
h ad b e c o m e high ly e n th u siastic a b o u t this lesson and had stored the
in fo rm a tio n in the d eepest recesses o f his brain. He would dredge it
up w h e n e v e r h e n ee d e d it (m ostly w h en h e was thirsty, w h ich was
m ost ol th e time), but h e did th e d o c to r o n e better. He reason ed that
if tw o w e re good, th en fo u r w ould b e better, eight would b e terrific,
six teen w ould b e ou tstand in g, an d so forth. Following th a t reasoning,
Ted sh ou ld h av e had the softest arteries a n d th e m ost relaxed tem ­
p e ra m e n t o f a n y o n e o n the planet. He didn't!

C o u n te r
W h e n w as th e last tim e you had ju st tw o drinks o f anything?

B eliefs
14. 1 can c u re m y drug p ro b lem w ith a little self-discipline
15. I can c o n tro l m y use if I try hard en o u g h

E x a m p le
M a n y hospitals offer intensive, inpatien t treatm en t program s for
alco h o lics a n d addicts. W e c o n d u ct tw o g ro u p -th e ra p y sessions in the
m orn in g , tw o classes in th e afternoon, and m eetings in the evenings.
The treatm en t runs for 6 days a week. Patients are allow ed n o distrac­
tions, holidays, or days off. T hey m u st c o n ce n tra te fully o n their recov­
ery, an d it's a lot o f work. O ver the years w e h av e found so m e patients
don 't w an t to do th e w ork; th ey th in k that a little self-discipline is all
th e y need.

C o u n te r
C h em ical add iction is o n e o f the m ost difficult problem s you can
have. C om p ared w ith so m e o th er troubles like phobias, depression,
a n x ie ty reactions, and the like, fewer p eople recover. W hy? T he an sw er
is sim p le— you fight th e treatm en t. P h ob ic and a n x io u s patients are
u su ally so m ise ra b le that th ey listen carefully, try' to b e honest, and do
their h o m e w o r k religiously. But not you and your fello w addicts! You are
likely to evade, distort, ignore, n ot listen, refuse to do the hom ew ork,
and in gen eral try' ever)' m e th o d you can th in k o f to sa b o ta g e help.
You are m o re likely to sa b o ta g e not b eca u se you are inherently
sicker, lazier, m o re dishonest, or less intelligent or w orth w h ile than
others— you d o it b e c a u s e o f the n a tu re o f y o u r addiction.
B ein g an addict is like having tw o ta p e-reco rd ed m essages in you r
___________________________________ lHEjiwJlANfiBOffi-OE^COGNlTIV£lJi£RM I^l£CHNiQli£S.

brain. O n e tells y ou n ot to use. J h i s is th e m essag e th a t got y o u to pick

up o u r m an u al; it's y o u r sensible, realistic side. But y o u h a v e a n o th e r
tape; it co m es from y o u r craving fo r drugs. It tells you to use n o m at­
ter what. 1 .
Joh n , a client in o n e o f o u r groups, gav e a g o o d description of his
u sin g m essage; h e called it th e lizard. It is th e cra v in g a n ad d ict has
for a drug. He had read a story several years a g o th a t d e scrib e d s o m e ­
th in g like th e following:

A m a n died and w en t to Heaven. It was ju st as h e had im agined,

with gold en gates and St. Peter sitting b e h in d a d e sk in th e front.
T h o u sa n d s o f p e o p le m illed a ro u n d th e gates trying to get in. But
th e re w as so m eth in g different a b o u t th e m — all o f th em had a lit­
tle lizard sitting on th eir shoulder, a n d all the lizards w e re h o p ­
ping up an d d o w n a n d yelling in h igh sq u e a k y v o ices into the
ears o f th e people. T hey w ere saying th in gs like: You re in the
w ro n g place, it's a trick, don 't g o n ear th e m a n at th e desk
b eca u se h e will try to trap you here. This place w ill h u rt y ou ; lis­
ten to me, I'm th e o n ly o n e o n y o u r side. I’m y o u r friend, don 't
listen to a n y o n e else, get o u t o f h ere b e fo re it's to o late." T he m an
found that h e also had a lizard th a t w as sh o u tin g th e s a m e kinds
o f things. T he m a n w alked up to St. Peter and said, I d o u b t i f you
will let m e in. / have co m m itted m a n y sins th at I'm s o r r y for so
I am p ro b a b ly n ot g o o d e n o u g h to get in to heaven." B u t St. Peter
said, "No worries. E v ery b o d y is a sinner. A n y b o d y w h o w a n ts to
c o m e in is allowed and is w elcom e. T h ere is o n ly o n e rule, b u t I
can 't tell y ou w h a t it is; you h av e to find o u t fo r yourself." So the
m a n started to w alk th o u g h the gates. H alfw ay in h e hit so m e ­
thing. It was like an in visible shield an d h e cou ld n 't get th rou g h.
He kept o n trying b u t h a d n o luck, for h e kept b u m p in g against
the shield. Finally h e saw an angel o n th e o th e r side, w h o
p oin ted to a little sign o n the top o f the gate. It read: Lizards must
be restrained. T h e m a n put a m u zzle o n his lizard a n d w alk ed in.

All addicts a n d a lc o h o lic s are b o r n w ith lizards o n th eir sh ou ld ers.

T h ey u su ally h av e a father, m other, g ra n d p a re n t, u n cle, o r a u n t w h o
also had o n e o n th e ir sh o u ld e rs. T h e lizard lies d o r m a n t u ntil th e
person starts d rin k in g or e x p e r im e n t in g w ith drugs a r o u n d th e age
o f 14 o r so; t h e n the lizard sp rin g s to life. In itially it acts like a
sp o iled b r a t a n d screech es, "I w a n t s o m e d o p e. I w a n t a drink." If it
d o e sn 't get w h a t it w a n ts it th row s a t e m p e r ta n t r u m a n d plead s and
b e g s until it d oes. But th e m o r e th e lizard is giv en a drug, th e m o re
 Adjuncts

it d e m a n d s a n d yells for a n o th er, then another, th e n another.

As y o u get o ld er a n d m ore ex p e rie n ced with the lizard you start
telling it to shu t up, b e c a u s e you r e m e m b e r w h a t h a p p e n e d w h en you
fed it before. But y o u r lizard is sm art a n d co m es b a c k in various dis­
gu ises to fool you. So m etim e s it dresses u p as y o u r m o m (M oth er
lizard) an d starts w h isp erin g things like: "P oor dear. I'm o n ly trying to
h elp y ou . You are all tensed up; you need so m e drugs to relax." S o m e ­
tim es it disguises itself as a m a c h o friend (R a m b o lizard) and says
"W h a t are you so m e kind o f w im p? O f cou rse you can h a n d le a c o u ­
ple o f drinks. Stop b e in g such a chicken shit!" S o m etim e s it clothes
itself as a S h a k e s p e a re a n a c to r (H am let lizard) and m akes a speech
like. Oh, life is su ch toil, pain and misery, w e need so m e drugs to
en d u re o u r m e a n in g less fate." A nd so m etim es y o u r lizard gets really
sn e a k y an d ap p ears disguised as a therapist (Sigm und Freud lizard). It
tells y ou "Let's g o into th e pub, sit dow n and order a coke, ju st to show
how strong w e h av e g otten o v e r the p ow er o f drugs." (For m o re lizard
disguises, se e M e M ullin, Gehlhaar, & Jam es, 1990.)
No m a tter w h at trick, con, flim -fla m , or lie the lizard tells you, it
w an ts ju st o n e th in g— th e drug— and it will keep pressuring you over
and o v er again until it gets it.
You can n e v e r get rid o f y o u r lizard, b u t if you stop giving it drinks
it will shrivel up and o n ly rarely b o t h e r you. U ltim ately you have to
co n tro l it b y n ev er giving in; ju st a little discipline isn't goin g to do it.
You d o h av e the power, for you are stro n g e r th a n y o u r lizard. You
m ust, however, see throu g h its m a n y disguises and catch it in its lies.
T h e b est way to stop a c o n n in g lizard is to know th e con.

B elief
20. I can c o p e b etter with life b y u sing chem icals

E x a m p le
Life had alw ays b e e n difficult for Bruce. His father had a b a n d o n e d
the fam ily w h e n h e was th ree years old, and he had b e e n pushed
a ro u n d b y an a lc o h o lic stepfather, tw o o ld er b roth ers w h o used
co ca in e , and o th e r bullies. Things didn't hurt so b a d ly w h en h e drank
and used pills. Life seem ed a little bit less o v erw h elm in g and a little
m o re m a n a g e a b le with the chem icals.

C o u n te r
I f you lo o k u p th e word "cop e" in a dictionary, y o u will find it
m e an s "To con ten d , to strive, to struggle with." It c o m es from th e old
 T h f iitw -H a n d b o o k .. o e C q g n i ix v f T h fra py T e c h n iq u e s

French w o rd "cou per" w h ich m e an s "to strike a blow." In fact, th e old

d efin ition o f th e w o rd m e a n t to en g a g e in com b at.
W h e n y ou use a lco h o l o r pills or drugs to h a n d le life's p ro b lem s
y ou aren't cop in g with life. You aren't struggling, c o n te n d in g w ith dif­
ficulties, o r striking a blow ; you are d o in g th e op p osite. You are ru n ­
ning aw ay as fast as y ou can. D rinkin g an d takin g dru gs is a
yellow -bellied , ch ick en -h e a rte d , cow ard ly w a y of facing life th a t does
n o th in g to c o n q u e r problem s. U sing hides p ro b lem s u n d e r a c h e m i­
cal security blanket.
To co p e p rop erly w ith life you m u st en g a g e in co m b at. You m u st
attack y o u r p rob lem s an d strike a b lo w against them . S o m e tim e s you
win, so m etim es you lose, b u t y o u will b e far stro n g e r for havin g
en g aged in the battle. T he biggest b u lly you h av e to fight is y o u r ow n
addiction. It is a p ow erfu l adversary. Stop trying to escape. Fight back!

B elief
26. I can alw ays predict that I w o n 't lose c o n tro l o v e r m y se lf w h e n I
use.

E x a m p le
Roy listened to the stories o th e r clients told in a grou p session. He
heard h ow o th e r a lcoholics a n d addicts had assaulted loved ones,
d am aged property, and eng aged in o th e r o u tra g e o u s b e h a v io r w h en
th ey w ere d ru n k o r h igh — th in gs th at t h e y w o u ld n 't h a v e ev en
th ou g h t a b o u t doing w h en they w ere clean or sober.
Yet Roy felt h e was different. He was a b so lu tely su re th a t n o m atter
h ow h igh or d ru n k h e got, h e w ould n e v e r assault his wife, or a b u se
his kids, or g e n erally lo se co n tro l o f his behavior.

C o u n te r
Drugs an d alcohol affect th e parts o f y o u r b r a in th at c o n tro l y o u r
em o tio n s and y o u r prim itive b e h a v io rs (the su b cortical areas). O n ce
th e ch em ical gets into these areas y o u c a n 't c o n tro l yourself— in fact
you w on't ev en b o t h e r to try. No m atter h ow h o rrib le o r stupid it m ay
seem to you now, you c o u ld d o literally a n y th in g w h en y ou are high,
and you co u ld spen d th e rest o f y o u r life trying to m a k e a m e n d s for
w hat yo u 'v e done.
O ver th e years addicts a n d alco h o lics h a v e to ld us m a n y stories
a b o u t w h a t th ey did w h e n they w e re h igh o r drunk. All o f th e fol­
low ing stories are true.
Adjuncts

• A m a n w h o w as high w a n d ered across a railroad yard and decided

to ta k e a nap. He lay dow n with his feet across a track. A train came.
He didn't ev en kn ow w hat had h a p p en ed until h e found h im s e lf in
a h osp ital with his feet b an d aged . All o f his toes had b e e n cut off.
• A profession al m a n had always w an ted to travel. It was his life's
d re a m b u t h e had n ev er m ad e e n o u g h m o n e y to b e ab le to afford
it. Eventually, h e applied to attend an overseas con feren ce. His firm
g a v e him a rou n d -trip , n o n n e g o tia b le airline ticket and prepaid his
a c c o m m o d a tio n . It w as a o n c e -in -a -life tim e o p p o rtu n ity b ecau se
t h e fin a n cin g w as difficult to get. He w ent to th e airport with his
friends to have so m e farewell drinks in th e VIP lounge, got drunk,
and n ev er m a d e it to the plane. His fu n d ing was canceled and he
n e v e r t o o k his trip.
• An alco h o lic from Sydney, A ustralia had an arg u m en t with his wife.
He w e n t dow n to th e pu b with th e in ten tion o f drinking. He didn't
r e m e m b e r an y th in g after the first co u p le o f drinks until h e cam e
o u t o f a b la ck o u t 2 8 hours later. He found h im self o n a plane b o u n d
fo r Vancouver, Canada. He was flying at 35,000 feet so m ew h e re past
Tahiti. He had no idea h o w h e g o t there, b u t h e looked throu g h his
pockets an d found a return ticket dated a w eek later. He had som e
A ustralian m oney, his passport, a n d so m e lo o se change. He had no
idea w h e th e r h e had a n y luggage with him so o n arrival in Van­
c o u v e r h e ch ecked at th e luggage carousel. T h ere h e found on ly two
things: his g o lf clubs a n d an extra pair o f socks.
• A m an had b e e n charged o n th ree sep arate occasion s for driving
u n d e r th e influence. His license had b e e n su sp en d ed for three years
a n d he'd b e e n giv en a g o o d b e h a v io r b o n d with a w arning that h e
w ould b e im p rison ed if h e offended again. He was at w ork o n e day
a n d h ad b e e n drin king continuously. As th e day progressed he
b e c a m e in creasin g ly agitated a b o u t th e staff pilfering g o o d s from
th e firm. T h e m o r e h e d ra n k th e m o re c o n v in ced h e b e c a m e that it
w as his du ty as fo re m an to report the thefts to the authorities. So
h e c lim b e d in to his c a r and d rov e to th e local police station. Before
h e could say a w ord h e was arrested, locked up, and his car
im p o u n d ed .
• A m a n w as k n ow n to all his friends as a sensitive, com p assion ate
person. They'd n ev er heard him say an u nkind w ord or seen him
d o an u n k in d actio n w h en sober. O n e day h e w ent o n a h u ge b e n ­
der. He dragged h im self o n to a cargo ship o u t o f San Francisco
b o u n d for Sin gapore. He didn't kn ow w hy; h e ju st did it. W h e n he
g o t th ere h e w a n d ered arou n d for w eeks in a total d ru n k en stupor.
370
T he N ew H an d bo o k of C o g n i t iv e T h e r a p y T e c h n iq u e s

He finally fou n d h im s e lf traveling o n a train in India. H e sat in third

class, w h ich o n Ind ian trains m e a n s p e o p le h a n g all o v e r th e roofs
a n d on th e sides. He sat b y an o p e n w in d o w an d th e train started
to pull o u t from th e station. An Indian w as ru n n in g b e sid e th e train
and leapt o n to th e side, g ra b b in g th e window sill n ex t to th e man.
The train picked up speed and th e Indian signaled that h e w an ted
to b e pulled in. T he m an said to himself, "W ould n't it b e interesting
to see the exp ression in a m an 's eyes right b e fo re he's a b o u t to die?
So h e started to push th e Indian out o f the window . As the Ind ian
b egg ed to b e pulled in, h e put his h a n d on th e stranger's h e a d and
pushed as hard as h e could. T h e Indian lo o se n ed his grip, and
finally was o n ly hold ing o n to the window sill b y his fingertips. T he
m a n sla m m ed th e w in d o w o n th e Ind ian's fingers and started to
press dow n hard. Then, as su d d en ly as he'd started, h e stopped,
look ed startled, an d said to himself, "W h at am I doing?!" He o p e n e d
the w in d o w and pulled in th e m a n ju st in time.

E x a m p le 2. T herapist's Style
W h ile in Australia I w orked in a m a jo r p u blic hosp ital for a lco h o l
and drug addiction. T h ere I m e t psychologist Patricia G ehlhaar, o n e o f
Australia's p rem ier addiction therapists. W e w ere c o u n s e lin g a lco­
holics w h o had relapsed. T h ere are scores o f b o o k s and p rog ram s th a t
suggest causes fo r relapses b u t I asked Pat for her o p in io n . S h e said,
"Hear how th ey d e scrib e their relapses. Listen to th eir language."
I to o k h e r advice and heard patients m a k e sta tem e n ts like th e follow ­
ing:

"I slipped."
"M y AA m eeting started to drop off"
"The b o o z e tripped m e up."
"I fell o ff th e wagon."
"The b o ttle g ra b b e d me.”
"It cau g h t up w ith m e again."
"I g o t hooked."

1 learned that Pat was right. T h eir la n g u a g e sh o w ed w h y th e y had

relapsed and w h y they were su scep tib le to relapsing. T h eir w ords
described altitudes o f victim ization a n d helplessness. Put all o f th eir
phrases to g eth er and o n e finds th e c o m m o n c o r e th em e : T h e patients
look ed a t th e ir lives as a series o f uncontrollable events. T h eir phrases
suggested that they th ou gh t th e y w eren 't respon sible, th a t it w asn't
Adjuncts 371

th eir fault. Phrases like "1 slipped," "I fell o ff th e wagon," "It cau g h t up
w ith me," "I found m y se lf in jail," and "M y m o th e r w e n t a n d died on
me," im ply th a t s o m e th in g from th e outside was con tro llin g their lives.
It's not that th ey h ad chosen to drink again, to get divorced, to com m it
a crim e; it was th a t th e se kinds o f things h ap p en ed lo them.
I listened so m e m o re a n d found that n ot o n ly did they have the
attitu d e that they w eren 't resp on sib le for their relapses, b u t they also
had th e sa m e attitude a b o u t life.

"I fo u n d m y se lf unem ployed." — from a client w h o'd had a h alf

d ozen w arn in g s from his boss.
"The n ex t m in u te I found m y se lf divorced." — from a client who'd
had c h ro n ic m arital p rob lem s for five years.
"The train left w ithou t me." — from a client w h o was 2 0 m inutes late.
"I discovered I was broke." — from an addict w h o m a d e S I 000 dol­
lars a m o n th b u t paid $800 in rent.
"I found m y se lf in jail" — from a client w h o h ad n 't filed a tax return
for 10 years.
"I started d rin k in g again b e c a u s e I to o k m y m o th er on a holiday,
an d sh e w e n t and died on me."

This attitude was th e key to their problem . As long as th ey felt that

s o m e th in g external was con tro llin g their lives and m ak in g all o f these
h o rrib le things h a p p e n to them , they didn't h av e to take responsibil­
ity for their drug use o r th eir lives. T hey could always esca p e resp on ­
sibility b y saying, "It w asn't m y fault. T h e devil m ade m e do it. Don't
b la m e me, and don't ex p ect m e to d o an y th in g a b o u t it."
W ith an attitude like this a person could drink or use forever.
T h erefore it b e c a m e crucial to c h a n g e th eir language. But how?
After years o f trying m a n y different ap p roach es with th ou san d s o f
a lcoh olics and addicts, Pat G e h lh a a r discovered h e r cognitive c o n ­
fron tation tech n iq u e. It is an effective te c h n iq u e for the chronic, seri­
ou sly d e p e n d e n t alco h o lic o r addict— th o se addicts w h o have a
lifetim e o f using a n d drinking, w h o have b e e n th rou g h m ultiple pro­
gram s, w h o are at the term in a l stages o f their addiction. Her techniqu e
puts the patient in ex tre m e cogn itiv e d isso n a n ce b y using paradox
and irony. After b ein g flo o d ed with this ap p roach for m ore th a n a
week, few patients could m ain tain their excuses and denials; they
w e re then o p e n to m a k in g real progress in recovering from their
addiction.
Here is an e x a m p le o f how Pat w ould h an d le a patient w h o had
relapsed.
 T h e N ew H a n d bo o k oe C o g n it iv e T h e r a p y T e c h n iq u e s

THERAPIST: So w h y did y o ij start to drink again?

CLIENT: Well, m y AA m eetin gs started to drop off.
THERAPIST: Wait! Oh m y G od! W h a t a terrifying ex p e rie n ce! You
m e a n to say that you w ere w alkin g d o w n th e street o n e n igh t to
g o to a n AA m eeting, you turn ed the corner, an d su d d e n ly th e
AA m eetin g d isappeared in front o f y o u r v ery eyes? D rop ped
in to a ch a sm or so m eth in g ? W h a t a frigh tening th in g th at m ust
have b e e n fo r you.
CLIENT: Well no, ah . . . a h . . . ah. That's n ot w h a t I m ean. A h . . .
ah . . . Right b e fo re I d ra n k again, th e m e etin g s started to get less
. . . ah . . . you kn ow w h at I m ean, don 't you?
THERAPIST: No, I don't! You m e a n th ey started to can ce l m eetings
k n ow in g that y ou w ere c o m in g o r so m eth in g ? O r y o u w ould
sh ow u p an d n o b o d y would b e th e re b e c a u s e th ey ch an g ed th e
location ? W h at a n asty th in g for AA to d o to you.
CLIENT: Ah . . . ah . . . no, o f cou rse not! Ah . . . a h . . . oh, th e hell
w ith it! I stopped goin g to m eetings!
THERAPIST: Oh, well! Okay, then— now, w e h av e it straight. Now,
exactly w h y did you feel y o u didn't need to g o to m e etin g s a n y ­
m ore?

Pat resp on d ed to o th e r statem en ts in sim ilar ways. Sh e w o u ld attack

clients' langu age and force th em to see exactly w h at th e y w e re th in k ­
ing b e h in d th eir words.

CLIENT: I slipped up and d ran k a beer.

THERAPIST: You didn't slip. That's w h at p e o p le d o w h e n th ey step
o n a b a n a n a peel. It w asn 't a n accident. You w a n te d one, so you
got one.

CLIENT: I fell o ff th e w agon.

THERAPIST: You didn't fall off; y ou ju m p e d off.

And so it went. It didn't take G e h lh a a r’s clients long to sto p saying

things like, "I fell off, it tripped m e up, th e b o o z e c a u g h t u p w ith me,
I fou n d m y se lf divorced, sh e w ent a n d died o n me." Instead th ey
started to say, "I decided to drin k again," "I th o u g h t I didn't n e e d AA,"
"I was fired b e c a u s e I didn't sh ow up at work," "M y m o th e r died." A n d
then an interesting thing hap p en ed . Not o n ly did th ey start saying
things th e right w ay; they started to u n d ersta n d th em in th e right way.
T h ey realized that they w ere u ltim ately resp o n sib le for th e ir relapses
Adjuncts 373

a n d for their lives, and that th ey and th ey a lo n e could do som eth in g

a b o u t them .

C om m en t
T h e differences b e tw e e n th e tw o cognitive m od els o f addiction are
n o t as ex tre m e as presented here. O u r m o d el accepts that em o tio n s
can b e triggers (alth ou gh not causes) o f drug use, and th e o th e r model
a ccep ts that facilitating beliefs (perm ission to use drugs beliefs— i.e.,
o u r 4 2 beliefs) are likely to ca u se th e client to su ccu m b to urges (Liese
& Franz, 1996).
T h e m a jo r difference b etw e en th e tw o m od els is th at w e pay a great
deal o f a tte n tio n to w h a t clients say to them selves after they get a crav­
ing, not before. For seriously d e p en d en t clients the on ly th in g necessary
to d ev elo p a craving is time. T h e addict's b o d y b e c o m e s accustom ed
to a certain level o f th e drug, a n d w h en this level is reduced a craving
is set off. D e p en d en t clients d o not need to b e anxious, depressed,
b o red , angry, frustrated, or in crisis to use; all they need is th e crav­
ing.
A personal note. I am well aw are o f th e reactions o f so m e readers
to th e presen tation o f o u r cognitive treatm en t for th e seriously c h e m ­
ically d e p en d en t patient. It w ould h av e b e e n m y reaction for the first
15 years o f m y ca reer b efo re h a v in g w orked fu ll-tim e in drug treat­
m e n t program s, b e fo re I m et Pat.
I had b e e n using cogn itiv e therapy for ch em ically ab usin g clients
for years. It had b e e n successful with m a n y clients. T h rou gh m ost o f
the early part o f m y ca reer I had not m a d e a distinction b etw een treat­
ing th e a b u s in g versus treating the seriously d e p en d en t client. Cogni­
tive te c h n iq u e s w e re helpful with m ost o f them.
But w h e n I w ent to w o rk in p u blic drug and alcohol treatm ent h o s­
pitals, I fou n d that th e standard cognitive tech n iqu es that had worked
b e fo re seem ed to m a k e these patients worse. T he patients in th e pub­
lic h osp itals w ere tw o stan dard deviation s a b o v e th e m ean on the var­
ious c h em ical d e p e n d e n c y tests. T hey had lost their families, their jobs,
th eir finan cial resources, their physical health; m a n y w ere hom eless
and living o n th e streets. W h e n I tried to help these patients b y reduc­
ing th eir negative em otio n s, it gav e th em an excu se to keep o n using.
T h ey w ould say, "I am addicted b ec a u se I h av e em o tio n a l problems.
W h e n I solv e th ese problem s, th e n a n d o n ly th en will I stop drinking."
Pat tau g h t th e m to think, "The hell w ith m y em o tio n a l problem s. I
h a v e th e m b e c a u s e I h av e b e e n using and drinking for 2 0 years. First
I need to stop now! I'll w orry a b o u t th e o th e r stu ff later on."
T h e literature o n drug a n d a lc o h o l treatm en t d o esn 't o ften m e n tio n
this p op u lation and d o esn 't o ften d e scrib e th e cogn itiv e c o n fro n ta tio n
that is necessary. 1 b e lie v e th e reason for this is b e c a u s e m a n y profes­
sionals w h o write the tex tb o o k s don 't often see this typ e o f patient. I
h ad n 't until I w orked in th e A ustralian drug hospital. You don 't see
th ese patients in a college c o u n s e lin g c e n te r b e c a u s e th ey h av e long
sin ce d rop p ed o u t o f school. You d o n 't see th e m in private practice
b e c a u s e th ey h av e lo n g ago run o u t o f m o n e y and h av e used up all
o f th eir insurance. You don 't see th em in e m p lo y e r drug treatm en t
program s b ec a u se th ey w e re fired years ago. You d o n ’t see th e m in
o u tp a tien t clinics b e c a u s e they h a v e tried this rou te an d failed m a n y
tim es before. T h e on ly place you find th e m is in a p u blic hosp ital after
th ey h av e b e e n picked up o n th e street fo r their u n c o u n ta b le detoxes,
with their livers alm ost gone.
O n e final n o te a b o u t the c o u n se lo r style. This style is n o t fo r the
fain t-h e a rte d or in ex p erien ced therapist. It m u st b e d o n e correctly. Pat
was a m aster and had m o re th a n 2 0 years' ex p erien ce. For tw o years 1
o b serv ed m a n y Pat "w a n n a b es" w h o tried to du p licate h e r style but
failed miserably. In o n e session Pat could totally destroy a patient's old
cogn itiv e system w ith o u t destroying the patient. H er irony a n d p a ra ­
doxical m e th o d s con fron ted th e patient's th o u g h ts ra th e r t h a n the
patient; m a n y im itators w ere u n a b le to m a k e this su b tle b u t crucial
distinction.
M any o f th e patients didn't like their cognitive systems b ein g
destroyed; so m e b eca m e angry and w ould ev en w alk out o f treatm ent
saying, "I don't need to put up with this crap." But then som ethin g would
happen that I've never seen with a n y o th er counselor. A few w eeks o r a
few m onth s later, th e sa m e patient would c o m e back, d em a n d in g to see
Pat. I interviewed these patients and asked them, "After what h ap p en ed
in the therapy sessions with Pat before, w h y did you specifically com e
back to see her?" They all told m e the sam e type o f thing:

Yes, I was angry. 1 was angry b e c a u s e ev e ry th in g sh e told m e

w'as exactly and precisely correct, and I k n e w il! M y o n ly o p tion
w as to get the hell o u t o f there. But I also kn ew th at th e o n ly
c o u n se lo r w h o could e v e r help m e was her, b e c a u s e 1 cou ld n 't
fool her with all m y bullshit. So w h e n I was read y to d o so m e ­
th in g a b o u t m y problem , w h en I k n e w th a t I w o u ld die if 1 did­
n't stop using, I im m ed iately knew w h o I had to see.
Adjuncts 375

A few years ag o Pat retired from fu ll-tim e drug and alcohol c o u n ­

seling at th e p u b lic hospital. At h e r retirem ent, th o u san d s o f recover­
ing alco h o lics an d addicts from all o v er Australia and o th e r countries
sh o w ed their appreciation for all that sh e h a d d o n e for them .

F u rther In fo r m a tio n
T he specific cogn itiv e treatm en ts for drug d e p en d en cy presented in
this ch ap ter w ere created b y th e authors. M u ch o f the m aterial is taken
fro m tw o b o o k s — M e M u llin and G e h lh a a r (1990a) and M e Mullin,
Gehlhaar, an d Ja m e s (1990). T he graphs and the m a jo rity o f the
research c o m e from M e M u llin and G e h lh a a r (1990b). T h e theory,
research, and practice h av e b e e n presented at several international
c o n fe re n ce s o n the trea tm en t o f drug and alcohol d e p en d en cy (Adam­
s o n & G ehlhaar, 1989; M e M ullin, 1990; M e M u llin & Gehlhaar, 1990c).
O th e r research su p p ort for this ap p roach is provided b y Blum (1990),
Blum and T rach ten berg (1988), B o h m a n , Sigvardsson, and C loninger
(1981), Cloninger, B o h m a n , and Sigvardsson (1981), Deitrich (1988),
G ood w in , Schulsinger, H erm ansen, Guse, and W in o k u r (1973), G o o d ­
win, Schulsinger, Moller, H erm ansen, W inokur, and G use (1974),
Lum eng, M urphy, M cBride, and Li (1988). Schuckit (1984), and Schuckit
an d V id am an tas (1979).
T h e m o re traditional cognitive m od el is represented in m a n y goo d
b o o k s . A lth ou gh in disagreem ent with so m e c o m p o n e n ts o f ou r
m od el, A lbert Ellis and his colleagues provide a therapist-friendly
s u m m a r y o f REBT proced ures with addicts and alcoholics (Ellis, 1989;
Ellis & Velten, 1992; Ellis et al., 1988). M iller and Rollnick (1991) have
so m e ex cellen t m otivational strategies and even accept that seriously
d e p e n d e n t patients m a y requ ire a cogn itive in terven tion m odel sim i­
lar to G eh lh aar's (Miller, personal co m m u n icatio n , Decem ber, 1989).
B ru ce Liese offers a c o m p re h e n siv e picture o f present cognitive ther­
apy, in clu d in g th e n eed to co n fro n t patients appropriately an d effec­
tively (Liese & Franz, 1996). Baer, Marlatt, and M c M a h o n (1993), Beck
et al. (1993), and Clarke and Sau nd ers (1988) have so m e im portan t
principles fo r a n y therapist w h o w ishes to use a cognitive therapy
a p p ro ach w ith c h em ical a b u se clients.
376 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T h e N e w H a n d b o o k o f .C o g n itiv e T fie r a p y T e c h n i q u e s

C o g n itiv e F o c u s in g

Principles

In th e first edition o f this b o o k , cogn itiv e focu sin g w as treated as an

im p o rtan t b u t n o n e sse n tia l tech niqu e. F u rth er e x p e rie n c e w ith su p er­
vising b e g in n in g cognitive therapists, how ever, has sh o w n th at an ele­
m e n t o f focusing m a y b e n ecessary fo r a n y co g n itiv e in terv e n tio n to
b e effective.
The essential featu re o f focu sing is th e ability o f th e therapist to stay
in to u ch with the client's o n g o in g processing du ring th e th era p y ses­
sion. Processing e n c o m p a sses clients' feelings, a u to m a tic thoughts,
images, em otion s, attitudes or values, felt physical senses, m eanings,
or any o th e r elem en ts actu ally ex p e rie n ced du rin g th e session. If the
therapist is co n sta n tly in to u ch w ith th e clients' o n g o in g exp eriences,
cognitive tech n iq u es will b e on target an d are likely to b e effective. If
th e therap ist is not, tech n iq u es will lack m e a n in g for clients a n d the
therapy sessions will deteriorate into m ean in gless intellectualization.
It is hyp oth esized th a t process focu sing is a n ecessa ry b u t n ot suffi­
cien t c o n d itio n for all effective cogn itiv e therapy.
C ognitive focu sin g is o n e o f th e m ost difficult aspects to learn — it
involves m a n y subtleties th at requ ire careful c o n c e n tr a tio n on the
part o f th e therapist. It is a p roced u re th at takes practice (som etim es
years); very ex p e rie n ced therapists d o it well w h ile b e g in n in g th e r a ­
pists m ay not b e ab le to do it at all.

M eth o d 1. G en eral Focusing in C ognitive T h era p y

1. Focus o n the o n g o in g processing o f y o u r clients du rin g th e sessions.
The difference b etw e en an ex p e rie n c e d co g n itiv e therapist a n d a
b e g in n e r is th a t th e e x p e rie n c e d th era p ist u ses th e client's
resp on ses rath er th a n the therapist's ow n agenda as th e su b ject
m a tter o f th e therapy.
2. Focus on not o n ly w hat clients are telling y ou b u t also o n h ow they
are telling you. Pay close a tten tio n to th eir tones, exp ression s, e m o ­
tions, postures, a n d o th e r n o n v e r b a l cues.
3. W h e n you m a k e a n in terv e n tio n (e.g., ask a q u estio n , offer a n inter­
pretation, clarify a feeling, give an ex p la n a tio n , c o u n te r a thought),
im m ed iately focu s o n th e client's v erbal an d n o n v e rb a l responses.
Listen very carefully.
4. Follow you r clients' responses rather th a n you r original statem ent.
Adjuncts 377

T he client's responses will often reveal a n o th er underlying pattern or

b e lie f th a t is m o re fu nd am ental to th e problem you are examining.
5. C o n tin u e follow ing o n g o in g resp on ses w h erev e r they lead. Clarify
th e c o g n itio n th ey are revealing (e.g., self-con cep t, attribution, self-
instruction, exp ectation, c o n ce p tu al focusing).
6. Help clients to pay atten tion to th eir o n g o in g exp eriences (e.g., th er­
apist says, "I n o tice you are smiling"). T h e n help clients form the
e x p e rie n c e in to a cogn ition (e.g., client says, "I a m sm iling b ecau se
I th in k it's very fu n n y h e got so upset, b eca u se h e keeps pretend­
ing to b e so strong.")
7. W h e n clients sh ow c o n fu sio n a b o u t w h a t they m ean, help th em to
focu s o n th eir ow n feelings u ntil they ca n find th e cogn ition th at
clarifies it.
8. Keep w o rk ing o n finding th e cognition that co n n ects to their felt
m e a n in g (e.g., ''Yes, that's it!").

E x a m p le
O n e o f the w orld’s m ost ex p erien ced cognitive therapists is Albert
Ellis. After fiv e decades o f w o rk in g with all kinds o f clients in individ­
ual a n d g ro u p sessions, he has p ro b a b ly accu m u lated close to a h u n ­
dred th o u san d co u n selin g hours (DiMattia & Lega, 1990).
If you listen to Ellis's m a n y pu blished taped cou n selin g sessions or,
ev en better, his v id eo sessions, or, b est o f all, if you ob serv e h im in o n e
o f his m a n y p u blic sessions (tapes can b e o b ta in ed from the Albert
Ellis Institu te for Rational Em otive Behavior T h erapy in New York),
you will n o tice th e following characteristics:

• He focu ses o n th e client intently. Thou gh h e m ay b e b efo re an audi­

e n c e o f several h u n d red professionals, h e is con stan tly ob serv in g
w h at his client is saying, feeling, and show ing him. (Professionals in
th e a u d ien ce w h o w h isp er during his sessions do so at their own
peril. M o re th a n a few h av e heard, "If the p eople in the back can't
b e qu iet du ring this session, w e will b rin g them up here to see what
th eir p ro b lem m ay be.")
• He drop s his agenda to follow the client's present experience. He
follows a cogn itiv e fram ew ork, b u t it is a fram ew ork b ased on
w h e r e th e client is rath er than on w h ere h e is himself.
• He is a directive therapist, teaching, guiding, and instru cting his
client, b u t he im m ed ia tely and qu ickly stops his c o m m e n ts w h en
th e clien t m a k es a statem ent.
 T he N ew Han d bo o k oe C o g n u i v l T h e r a p y T e c h n iq u e s

• A lthou gh h e m a y strongly and assertively attack a belief, h e n ev er

attacks a client. He show s c o m p le te an d total respect fo r th e person.
• He takes clients as far as they are willing to g o d u rin g th e session,
b u t d o esn 't try to push th em to his end p oint b e fo re th e y a re ready.
• He shifts directions in sta n ta n e o u sly based on his clients' responses.
• He is h onest an d e m o tio n a lly transparen t. He d o esn 't h id e b e h in d
a professional facade o r pretend to b e distant, rem ov ed an d n o n ­
em otio nal. If a client asks h im a q u e stio n h e gives a n h o n e st
answer. For instance, a client m ight ask, "Well, w h a t w ould you do
in this situation?" Instead o f replying, "You w a n t to kn ow w h a t I
think?" or "You feel u n co m fo rta b le decid in g for yourself," o r "W e are
talking a b o u t you, n ot me," Ellis will an sw er the clien t directly and
honestly.

M eth o d 2. One Specific C ognitive-focusing P rocedu re

1. Ask y o u r clients to relax and ease a n y tautness in their m uscles.
Have th em recline and close th eir eyes if th ey wish. (3 m inu tes)
2. Urge them to clear their m in d s and to focu s inw ardly w h ile you
set the scen e for th e exercise. If th ey haven't c o m e to you w ith a
specific problem , present them w ith an an a log )' to help u n co v er
the m a jo r sou rces o f th eir discom fort. An e x a m p le o f su ch an
analog)' follows:

Im ag ine that you are sitting in a s to re ro o m cluttered with

boxes. In each b o x is o n e o f y o u r problem s. Each p ro b lem has
a different b o x and th e largest b o x e s c o n ta in th e largest p ro b ­
lems.
Now picture y o u rse lf m o v in g th e b o x e s o n e at a tim e into
th e co rn ers o f the r o o m so that you can h a v e sp ace to sit
down. From a relatively co m fo rta b le perch in th e m id d le o f
the room , survey th e b o x e s a ro u n d you carefully. Pull o u t th e
b o x that y o u m ost w ant to o p e n a n d o p e n it.
Lift the p rob lem o u t o f th e b o x and lo o k at it. Turn it from
side to side so th at y ou can see ev ery aspect o f it. Try to step
outside y o u rse lf an d w atch you r reaction s to it.

3. O n c e clients h a v e selected a p ro b lem fro m th eir "storeroom ," ask

th em to focu s o n h ow th ey feel a b o u t that p ro b lem . For e x a m ­
ple, o n e o f o u r clients rep o rte d feeling u n c o m fo r ta b le w h e n e v e r
sh e m e t h e r sp o u se's ex-w ife. W e asked h e r to fo c u s o n h ow s h e
felt a b o u t th ese m eetings. S h e tried to recrea te th e fe e lin g in the
Adjuncts, 379

p resent r a th e r th a n sim p ly re m e m b e r in g w h at sh e felt.

4. Instru ct you r clients to focu s o n the overall em o tio n that b est c a p ­
tures h ow they feel ab o u t t h e problem . This will b e m ore difficult
for s o m e clients th a n for others, and it w on't b e easy for anyone.
M a n y clients are co n d itio n e d in w ays that prevent them from
clarifying their feelings, eith er to them selves or to others. Feelings
are u su ally co m p o site s rath er th a n single entities, w hich could
m a k e it difficult for clients to easily sense o n e overall impression.
Clients m u st s u b d u e all o f th e self-sq u aw kin g and ja b b e r in g that
m ay b e g o in g o n in th eir heads b efo re they can recognize th e
overall em o tio n . In o u r exam ple, after m u c h effort, th e client was
a b le to label th e e m o tio n associated with m e etin g her husband's
e x -w ife as anxiety.
5. O n c e th e overall e m o tio n has b e e n defined to y o u r clients' satis­
faction, in volv e th e m in a careful analysis o f th e various nu ances
and c o m p o n e n ts o f th at feeling. Since feelings are usually c o m ­
posites, e le m en ts o f anger, guilt, resentm ent, jealousy, etc., could
b e ev id en t in a n d arou n d th e central em o tio n o f anxiety.
6. Now h av e y o u r clients recall in detail o th er sim ilar situations in
w h ich th ey h av e felt th at sa m e em otio n . ("Have you always
reacted fearfully w h en you m et his ex-w ife? W h e n you met
s o m e o n e else, like y o u r m o th e r -in -la w or his ex-girlfriend?
D escrib e th o se o th er situations. Tell m e exactly how you see you r­
s e lf feeling a b o u t each o n e o f them.") Have y o u r clients resonate
th e situ atio ns w ith th e feelings so that you can confirm that there
is an ap p a ren t "association" b etw een th e overall em o tio n (anxi­
ety) and th e m eetings. T he situations can b e draw n from the past
as well as from th e present.
7. M o st im portantly, p ro b e to d e term in e w hat thou gh ts sparked the
s a m e e m o tio n in each o f th ese sim ilar situations. In each instance
d e te rm in e w h a t y o u r clients have b e e n saying to themselves.
W h a t m e a n in g d o th ey assign to th ese situations? Follow th e trail
suggested b y each o f th ese c o m p o n e n ts to se e if it leads to a mis­
ta k en co re p e rce p tio n h eld b y th e client. In o u r ex a m p le the fol­
low ing core p ercep tion em erged : "I am not as goo d as sh e is.
W h e n m y h u sb a n d sees us to g eth er h e will realize he m ad e a
m istake leaving h e r for me."
8. Now try to help y o u r clients sw itch th e em otio n . T he first step is
to ask th em to focu s o n sim ilar situations that did not incite the
n eg ativ e overall em otio n . ("Was th e re ev er a time w h en you m et
his e x -w ife th a t was not u psetting to you? D escribe how you felt
 then.") R em ind th em not tp sim p ly recall w h at th e y ex p e rie n c e d
b u t to try to recreate th e s a m e feelings. (If y o u r clients can o n ly
recall h a v in g th e n egative overall em o tio n , ask them to focu s on
h ow o th e r p eople m ig h t feel in th e s a m e situations.)
9. Next, instruct y o u r clients to focus o n th e ir thou ghts, beliefs, or
w h at th ey told them selv es du ring th ese sim ilar situ ations w h en
the overall e m o tio n was different. ("D escribe h o w you th o u g h t on
th o se o ccasion s w h en you w eren 't an x io u s a b o u t m eetin g her.")
G uide y o u r clients th ro u g h an analysis o f th ese feelings. In o u r
exam ple, th e resulting core p ercep tio n th a t em erg e d w as: "I feel
sorry fo r her. Sh e is a g o o d person ju st like m e. Not b e tte r or
worse, ju st a n o th e r h u m a n b e in g th at has had difficult tim es like
myself. He is w ith m e now, n ot her, b u t h e still cares fo r h e r and
I can accept his carin g and learn to like h e r myself."
10. Finally, h av e y o u r clients practice rep lacin g th e feelings th at th ey
had initially (steps # 4 and #5) w ith th e feelings in th e o th e r situ­
ations (step #8). T h e key to sw itching th e e m o tio n s is sw itching
th e thoughts. Have y o u r clients im ag in e th e th o u g h ts th e y had
w h en th ey w eren 't a n x io u s (step #9, ra th e r th a n step #7). In o u r
exam ple, the client pictured b elie v in g that th e e x -w ife w as a g o o d
person instead o f th in k in g th a t h er h u sb a n d w o u ld regret th e
divorce. D ep en d ing u p o n th e severity o f th e d a m a g in g p r e o c c u ­
pation, ex p e ct this practice to c o n tin u e for q u ite s o m e time. Teach
y o u r clients h ow to practice this shifting te c h n iq u e at h o m e using
a variety o f c o n cre te ex am p le s from their ow n histories. T h e m o re
th ey practice, th e m o re proficient th ey will b e c o m e at shifting
from negative to positive em otio n s, and the m o re d u ra b le the
positive shift will be.

E x a m p le: T he Story o f L ester

Lester, in his forties, was h av in g a great deal o f difficulty w ith his
ro m an tic relationships. He d escribed diverse feelings in a v ery c o n ­
fused, d isco rd an t m anner. N evertheless, he w as p sy ch o lo g ica lly
sophisticated and a professional writer. W e used th e s to r e r o o m a n a l­
ogy to help h im focu s o n the central problem . T h e m ain c o m p o n e n ts
o f the dialogue, w hich to o k an h o u r and a half, are su m m a riz e d here.

LESTER: I see several big boxes. O n e has m y p ro b lem o f b e in g je a l­

ou s w h en the w o m a n I a m g o in g o u t with sh ow s interest in
a n o th e r m an. A n o th e r p ro b lem is th e in n e r co n flict I feel o f
Adjuncts 381

w a n tin g to b e very close to h er b u t at the sa m e tim e feeling

"trap ped " if 1 get to o close. A third problem is m y in ability to hurt
a w o m a n w h o m I like as a person b u t don 't particularly w ant as
a m ate. 1 can 't seem to b rea k o ff th ese relationships. A n o th er b ox
is th e lo v e -h a te -f e a r -jo y -a n g e r conflict I h a v e with a w o m an I
have fallen in love with. T h e fifth b o x is my propensity to pro­
tect m y se lf by always goin g out with several w o m en at the sam e
time, ev en th o u g h o n e is alw ays special.
THERAPIST: Pull o u t o n e o f the b o x e s from the co rn er— a n y o n e
y o u w ish — a n d put it in front o f you. O p e n it up and lift the
p ro b lem o u t o f it. Just lo o k at it. G et th e feel o f th e w h o le prob ­
lem. T h ere are p ro b a b ly m a n y aspects to it— to o m a n y to th in k
o f separately, so try to get th e total feel o f it. Look inside o f you r­
self w h e r e you feel things and see w h at co m es to you as you look
at th e problem . W h a t co m es up w h en y ou ask y o u rse lf "How
d o e s it feel now?" Just let th e feeling c o m e in w h atever way it
c o m es b u t don 't g o inside o f it. Keep look in g at it from th e out­
side. (3 m inutes)
LESTER: I pulled out the largest box, the love-hate-fear-joy-an ger box.
W h e n I opened it I saw all these swelling emotions. It felt familiar,
for I have seen this b ox m an y times before. I rem em ber noticing
that at different times there are different dom inant emotions—
som etim es the fear, other times the love, frequently the anger.
THERAPIST: W h a t w as y o u r overall reaction to the problem ?
LESTER: C onfusion.
THERAPIST: L oo k for a label for you r overall feeling, like "sticky,”
"tight," "confined." Keep focu sin g o n the overall feeling and try
different w ords or pictures until o n e clicks. (4 minutes)
LESTER: T h ere is a feeling o f great sadness and loneliness. It feels
v ery empty. It also feels twisted— like all these e m o tio n s don't
b elo n g , like th ey c o m e from so m ew h e re else and have just
attached th em selv es to the relationship. T hey are very old feel­
ings, like th ey started long b efo re I dated. M ostly though, I feel
regret th at th ey are there. T hey seem to b e m u dd ling w hat o th ­
erw ise would b e a clear p o o l o f goo d feelings.
THERAPIST: Fine. Now I would like you to search for situations that
are co n n ected to th ese em otion s. Find events in the present and
o n e from th e distant past. Keep focusing o n you r feelings until
so m e situation occu rs to you. Take each overall em otio n o n e at a
tim e, and w ait until an ev en t attaches itself to the em otion . (3
m inutes)
 T he N ew H a n d bo o k qf C o g n i t iv e T h era py T e c h n iq u e s

LESTER: Ever)' tim e I am with a w o m a n I feel sad and lonely. I felt

this s a m e feeling w h en I was in g ra d e sch ool. 1 didn't fit in and
1 felt I didn't h av e a n y friends a n d n o b o d y liked me. T h e twisted
im pression c o m es a day o r tw o after I a m w ith a w o m a n . I
r e m e m b e r feeling this m a n y years ago w h e n I fell in love for the
first tim e. M y feelings for her didn't seem q u ite real; th e y seem ed
kind o f neu rotic o r som ething.
THERAPIST: Okay. Keep focusing on y o u r em otio n s silently b u t this
time lo o k for the core b e lie f that ties the past a n d present situa­
tions to you r em otions. Take each feeling o n e at a time. (5 minutes)
LESTER: Yes, th e sad and lo n e ly feeling co m es from th e th ou g h t, "I
am different from others. In so m e way I am sep arate from the
rest o f hum anity. I am not like o th e r people."
THERAPIST: And the twisted feeling? W h a t th ou g h t m a k es you feel
that the em o tio n s are w ro n g a n d o u t o f place?
LESTER: Yes, m y th o u g h t is th at feeling this w ay is sick a n d I m u st
b e inferior to o th e r m en.
THERAPIST: Can you tie th e tw o th ou g h ts together?
LESTER: I ca n b eg in to see w h at I am thinking. "I am different from
the rest o f h u m a n ity b ec a u se I am sick." I th o u g h t this w h e n I
w as in grad e school, th e different and inferior parts— b u t th ey
turned to a feeling o f b e in g sick w h e n I fell in love w ith m y first
girlfriend. N ow adays I d o n 't feel this often, o n ly w h en I start
d eeply caring for a w o m an.
THERAPIST: Very- g o o d work. Now let's try so m e shifting. I w an t
you to focu s on so m e different situations. Try to th in k o f so m e
tim es w h en you w ere w ith a w o m a n b u t you felt calm , confident,
and healthy.
LESTER: There h av e b e e n lots o f w o m en I felt g o o d with, b u t I never
cared for them. If I fall in love with a w o m a n then I get th ese b ad
feelings.
THERAPIST: All right. T h en lo o k for th e tim es you h av e b e e n w ith
th ese w o m en w h o you love w h en y ou h aven't felt th e se e m o ­
tions. Take y o u r tim e and find several situ a tio n s from the past
and present.
LESTER: Well, th ere h a v e b e e n sh o rt p eriods o f tim e, u su ally lasting
on ly a few days, w h en I didn't feel them.
THERAPIST: Take so m e tim e now, silently w ith yourself, an d focus
o n w hat you w ere feeling at th e se times. (3 m inu tes)
LESTER: I can feel it. Free! Not jealous. H appy to kn ow th e m and to
love them .
Adjuncts 383

THERAPIST: Okay. W h a t did you perceive du rin g th ese tim es that

you didn't p erceiv e in th e others? W h at did you say and believe
differently? Be silent with y o u rse lf a n d see w h a t c o m es up. (1
m inute)
LESTER: I was th in k in g I didn't need them . I w an ted th e m b u t I did­
n't h av e to have th em . See, b efore, I felt these w o m e n I loved
w ere m y o n ly contact w ith th e rest o f hum anity. W ithou t them I
was totally alone. B u t at the o th e r tim es I felt like I was a part o f
h um anity, like I had m y u n iq u e individuality b u t I was not
a lon e. W h e n I th o u g h t that way, m y lovers were just people, not
saviors th ere to rescue m e from loneliness.
THERAPIST: Please continue.
LESTER: T h ere are tim es w h en I am with th e w o m a n I love w h en I
c an see things clearly. T h ese times o n ly c o m e occasionally,
m a y b e fo r a d ay o r so, and then I slip back into the old murky
pool. It feels like I can see her as a sep arate individual, with her
ow n struggles, trium phs, a n d tragedies. I don't th in k she only
exists to m a k e m e feel g oo d . It's like I lose m y self during these
tim es a n d see h er as in d e p en d en t o f me.
THERAPIST: Please stay with this feeling. Keep focu sin g on it. Now,
try so m eth in g . W h ile b e in g in the feeling, look b a ck at th e old
feeling. View' the old felt sense o f b e in g different, twisted, and sick
from th e perspective o f y o u r new feeling. (2 m inutes)
LESTER: O h my! T h e old feeling is n o t real. That's w h y I called it
twisted. It is incredibly arrogant. W h a t conceit and narcissism to
b e lie v e that n a tu re created m e separately from others! It's like
na tu re had tw o creations— e v ery b o d y else in the world, and then
me. That m akes m e as im p o rtan t as all the rest o f hum anity. I am
so special I needed an in d e p en d en t genesis! It is a self-ind ulgent
selfishness to d e m a n d th at a w o m a n give up h erself to m inister
to m y arrogan t loneliness. Hell, w e are all lonely; w e are all
trapped in sid e o u r ow n skins w ishing to b e part o f a "we" rather
th a n ju st an "I." M y feeling o f b e in g different from all o th e r p eo­
ple is ju st an exercise in cosm ic vanity, an existential snobbery.
THERAPIST: Hold that perception. Tuck it away so m ew h e re in a
safe place. Call it u p w h en y o u r are staring at the b ig b ox o f c o n ­
tradictory em otio n s. Pull it o u t w h en you are with the w o m an
you love and are feeling angry, hurt, lonely, and hateful.

T h e sessions c o n tin u e d using cognitive focusing. Lester would kept

m o v in g a m o n g situations, feelings, an d thou ghts. W h e n h e was with
384 T h e N e w H a n d b o o k , oe Co g n it iv e T h e r a p y T e c h n iq u e s

his lover h e practiced c h a n g in g his p ercep tio n th at h e was u n iq u e ly

different and sw itched it to "I am part o f hum anity. I am n ot alone."

C om m en t
T he term "focusing" is adapted from th e w o rk o f th e w e ll-k n o w n
Rogerian theorist Eu gene G end lin (1992a, 1992b, 1996a, 1996b). S o m e
research indicates that focu sing m ig h t b e the active e le m e n t in Roger­
ian therapy, p rod ucing high levels o f client se lf-e x p e rie n c in g (Me
M ullin, 1972). But in th e p resent c o n te x t focu sin g m e an s b o t h less and
m ore th a n w h at G end lin describes; less b e c a u s e G en d lin has created
a w h ole therapy b ased o n th e con cep t, fo c u sin g -o rie n te d p sy ch o th e r­
apy (Gendlin, 1996a), and m ore b e c a u s e h e discusses co g n itio n s o n ly
as a c o m p o n e n t o f his p roced u res (Gendlin, 1996a, pp. 2 3 8 -2 4 6 ), and
believes that cogn itiv e m e th o d s sh o u ld b e "o cca sio n al and brief"
(Gendlin, 1996a, p. 246). W e a rc n o t ad v o ca tin g th e ex a ct du plication
o f all o f his procedures; o u r position is th at cogn itiv e fo cu sin g is at th e
very co re o f b o th his and o u r therapy.
To explain w h y focu sin g is so im p o rta n t it m a y b e useful to briefly
review the key theoretical assu m p tion u n d erly in g cogn itiv e restruc­
turing therapy.
The central feature o f cognitive th erap y is to shift th e c o r e b e lie f (B)
that co n n ects th e e n v iro n m e n ta l stim uli (A) to th e e m o tio n a l (Ce) and
b eh av io ral resp onse (Cb). T he focu s is o n th e B, u n lik e o th e r therapies
that m ay direct a tten tio n to o th e r elem ents. For instance, Rogerian
therapy focuses o n the Ce, assu m in g th a t if clients are in to u ch with
their o n g o in g se lf-e xp e rien cin g then th ey will g ro w and c h a n g e in a
positive direction. B ehavioral th erapies direct th eir a tten tio n at th e A -
C co n n ec tio n and aim to b r e a k dow n old asso ciations o r d ev elo p new
ones. P sych od yn am ic th erap y u n cov ers the original A -C e exp eriences,
b elie v in g that w h en these c o n n e c tio n s b e c o m e co n scio u s th e a sso cia­
tions b e tw e e n th e tw o will w eaken and th e n b e broken.
O th er therapies often criticize the cogn itiv e a p p ro a ch b e c a u s e th ey
view m a n y Bs as eith er su p erflu o u s (behaviorism ), intellectu alizations
(Rogerian), o r defense m e ch a n ism s (psychodynam ic). But th ese criti­
cism s are b ased o n a very narrow view o f w h at a B is. T hey view Bs
as w ords or language. If Bs are o n ly words, th e n m u ch o f cogn itiv e
therapy would deteriorate into investigating rationalizations, in telle c-
tualizing, or la n g u ag e shifting, b u t a m a jo r th e m e o f this b o o k is that
Bs are m u c h m o re th a n language.
In th e early part o f this b q o k w e d e scrib e Bs as: ex p ectatio n s, selec­
 385

tive m em ories, attributions, evaluations, life them es, in n er philoso­

phies, self-efficacy, and cogn itiv e m aps as well as o th e r cognitive
processes. Bs can b e g ro u p e d an d d escribed as the way the brain organ­
izes raw data into patterns. So Bs are far m ore th an words. Words and lan ­
g u a g e are sim p ly w ays o f c o m m u n ic a tin g the patterns; th ey are not
th e patterns them selves. Even if clients had no words to describe their
p atterns (as is often true w ith y o u n g children), th e patterns are still
there. T h e p u rp o se o f cogn itiv e th erap y is n ot to ch a n g e the client's
la n g u a g e b u t to c h a n g e th e client's patterns.
T h e d a n g e r in the use o f the specific focu sin g te c h n iq u e lies in
overm ystifyin g th e process. Focusing narrow s clients' atten tion on
th eir e m o tio n s so that th ey can m o re easily identify th e external trig­
gers a n d in terven ing cogn ition s cau sin g th ose em otions. T he beliefs
that clients find are th erefore m o re likely to b e precise, and a n y cog­
nitive c h a n g e te c h n iq u e is m ore likely to b e effective. T h e process is
n o t based, in o u r view, o n getting in to u ch w ith hidden elem ents
inside o n e 's su b co n s cio u s or on repressed em o tio n s that need to be
ex p u n g e d ; rather, it focu ses clients' atten tion o n specific, m a n a g eab le
p ercep tio n s th a t can b e usefully shifted.

F u rther In fo r m a tio n
T he theoretical, practical, an d research basis for the focusing tech ­
n iq u e can b e found in G endlin's works (1962, 1964, 1967, 1969, 1981,
1991, 1992a, 1992b, 1996a, 1996b; G endlin, Beebe, Cassues, Klein, &
O berlander, 1968).

Co r e C o m po n en ts o f C o g n it iv e

R e s t r u c t u r in g Th e r a p y : A C h e c k l is t

Principles

C on d u ctin g cogn itiv e therapy is b o th an art and a science. There are

th o u sa n d o f p roced u res a n d tech n iqu es that need to b e mastered, and
a lth o u g h th e key principles co n n ec ted with th e science can b e learned
q u ickly th ro u g h an a c a d em ic cou rse o r b y reading a few g o o d text­
b o o k s , it takes a lot lo n g er to lea rn all the subtleties o f the art. Having
su p erv ised g rad u ate stu dents for over 25 years, I estim ate that novi­
tiates sh ou ld not d o cogn itiv e therapy independently, until they have
h a d tw o years' clinical ex p erien ce; this tim e period allows for o n e
 T iii; N e w H a n d b o o k o f Co g n it iv e T h e r a p y T e c h n iq u e s

su pervisory session a w eek I q review th eir tap es and critiq u e their

counseling , and assu m es that th ey are c o n tin u in g their stu d y o u tsid e
th e sessions.
Despite th e diversity o f skills that can b e learned, th e re are a few
key principles th at therapists m u st teach their clients i f co g n itiv e th er­
apy is to b e effective. Follow ing is a list o f essen tial questions.

1. Can clients distinguish b etw e en situations, thou ghts, and e m o ­

tions o r do th ey co n fu se the three? R e m e m b e r that situ a tio n s are
an e n v iro n m e n ta l v a ria b le ou tsid e th e organ ism , th o u g h ts are
fro n ta l-lo b e processing, and e m o tio n s are su b co rtical feeling
responses. (See c h a p ter 1, "First Session: T eaching th e Basic For­
mula.")
2. Do y o u r clients b eliev e that th ou g h ts cau se em o tio n s, o r d o they
still th in k that situ ation s elicit feelings? T h ere is no point in c o n ­
tin u in g a cognitive therapy if y o u r clients c o n tin u e to b e lie v e that
outside physical events are cau sin g th eir em otio n s. (See ch a p ter 1,
"Providing Evidence that Beliefs P ro d u ce Emotions.")
3. Have y o u r clients fou nd th e co re beliefs linked to th e ir em o tio n a l
responses? If the beliefs you are w o rk in g with are irrelevant to
the client's em o tio n s then c h a n g in g th em will not re m o v e the
em otion. T h e first step in cogn itiv e co u n selin g o f all typ es is to
clearly identify th e m ost b asic b e lie f th at is c a u sin g th e client
problem s. T he beliefs that clients are aw are o f are u su a lly o n ly the
su rface thou ghts; th e therapist o ften n eeds to dig fo r several ses­
sion s b efo re the co re is uncovered. (See ch ap ter 2, "Findin g the
Beliefs.'')
4. Do th e clients see the negative effects o f th eir beliefs o n th e ir lives,
o r do th ey th in k that th eir th ou g h ts are irrelevant to w h a t th ey
feel and how they act? (See c h ap ter 1, "H ow Powerful A re Envi­
ron m en tal Forces?")
5. Can th e clients discern the interrelationsh ip b e tw e e n o n e th o u g h t
a n d a n o th er? Do they see that th eir fear in a grocery' store is fun­
d am en tally th e s a m e as th eir fear in a restaurant, elevator, o r c o n ­
fe r e n c e r o o m ? C an t h e y draw a c o g n itiv e m a p of th e se
relationships? (See c h a p ter 3, "G roups o f Beliefs.")
6. Do they u n d erstan d the n eed to an a ly z e th e usefulness o r false­
ness o f their beliefs o r d o they th in k th at feeling so m e th in g
strongly establishes its validity? (See c h a p te r 6, "Finding th e G o o d
Reason.")
7. Can th ey successfully an alyze sta tem e n ts a n d m a k e d e cisio n s as
Adjuncts_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ ________ 387

to th eir u sefu ln ess o r falseness? (See c h a p ter 6, "Logical Analysis.")

8. H ave th e y c o m m itte d to the idea that if a th o u g h t is logically false
it is useful to c h a n g e it? (See ch ap ter 6, "Utilitarian Counters.")
9. A re y o u r clients w illing to g o against their beliefs? Have they
d ev elo p ed the m o tiv atio n to use various m e th o d s (countering,
p erceptual shifting, resynthesizing) to c h a n g e them , or are they
sim p ly g o in g th ro u g h th e m o tio n s w ithout really w anting to
w ork o n an yth in g ? (See chap ter 4, "C ounterattacking" and "Forc­
ing Choices.")
10. Have th ey practiced th e tech n iqu es en o u g h ? (S om e beliefs m ay
ta k e a y e a r or m o re o f practice.) Unfortunately, m an y clients
b e lie v e in m agic and th in k that o n e aftern o o n o f disputing will
m a k e up for 15 years o f b elie v in g an irrationality. Clients need to
practice o v e r a long period o f tim e n o t rather th an sim ply w hen
th ey are in crisis. (See c h a p ter 11, "Practice Techniques.")
11. Do th ey use the procedures m ech an ically or have they show n that
th ey u n d erstan d th e u n d erly in g concept? (See ch ap ter 8, "Trans­
p osing Images," and c h ap ter 9, "Bridging")
12. H ave th ey m od ified you r procedures so m uch that th ey have
destroyed th e activ e th erap e u tic ele m en t? Client creativity is to be
en c o u ra g e d b u t you need to m ak e sure that th e client doesn't
c h a n g e the te c h n iq u e so m uch th at it b e c o m e s ineffective.
13. Do y o u r clients recognize that therapists don 't have the pow er to
c h a n g e beliefs and that o n ly th ey have that pow er? Do they
accept th e co u n selin g relationship as m o re o f a teach er-stu d en t
th a n that o f a d o cto r and patient, or are they waiting for you to
cu re them ?
14. Are th e clients' percep tion s o f th erap eu tic efficacy so low that
th ey ex p ect th e th erap y to fail? T he research on self-efficacy is
rath er strong o n this point; if clients ex p ect to fail they will often
d o su b tle things to help m a k e their prediction c o m e true. (See
c h a p ter 2, "Self-Efficacy.")
15. Do th ey th in k th a t a n o th e r a p p roach o r a n o th e r therapist would
h elp th em m o re ? T h ey m ay n ot put a n y effort into y o u r therapy
if th ey feel it is se co n d best. Suggest that th ey try the o th er
a p p roach first and th en return to you if it proves ineffective.
16. Do clients c o m p le te th eir h o m e w o rk o r d o they on ly w o rk during
y o u r th erapy sessions? O n e h o u r engaged in the right direction
does not offset 112 h ou rs o f w o rk in g in the w ron g direction. (See
c h a p ter 1, "Learning th e Concepts.")
17. A re y o u r te c h n iq u e s in effectual b e c a u s e the clien t is sab o ta g in g
388 T h e N e w H a n d b o o k o r C o g n it iv e T h e r a p y T e c h n iq u e s

th e m ? (See c h a p te r 12, "H a n d lin g C lien t Sabotages.")

18. Have you fou n d th at so m e o f y o u r clients h a v e difficulty c h a n g ­
ing beliefs that are an ch o red to th eir person al or cultu ral h isto­
ries? C han ging th ese typ es o f th o u g h ts o ften ev o k es feelings o f
guilt; y ou m ay b e required to pull th ese beliefs o u t b y th e roots.
(See chap ter 10, "Historical Resynthesis" a n d c h a p ter 13, "C ross-
cultural C ognitive Therapy.")
19. Are there to o m a n y n o n c o g n itiv e factors in terferin g w ith y o u r
tech n iq u es? A lthou gh y o u r clients' cen tra l p ro b lem s m a y b e c o g ­
nitive, in ord er to effectively w o rk o n th em th ey n ee d to have
b o th tim e an d freedom from co n sta n t crisis in o rd e r to effectively
c h a n g e th eir n egative perceptions. Clients with severe m arital
problem s, physical illness, drug a b u se issues, o r w h o a re not sure
o f w here th eir next m eal is c o m in g from are not in th e right fram e
o f m ind to w'ork o n th eir cogn itiv e problem s. In su ch situ atio n s it
is b etter to m itigate the crisis b e fo re you attem p t tra d ition a l c o g ­
nitive therapy. (See c h a p ter 12, "Crisis C ognitive Therapy?' "Treat­
ing Seriou sly M en tally 111 Patients," "C ognitive R estructuring
T h erapy with Addicted Patients.")

E x a m p le
Psychotherapy has failures like a n y o th e r profession, b u t profes­
sion al therapists w riting a b o u t their te c h n iq u e s often o n ly sh o w the
public th eir successful cases. In n ew sp ap er articles, b o o k s, jo u rn als,
and o n talk shows, therapists talk a b o u t th o se p e o p le w h o m th ey h av e
helped. This creates th e p ercep tion that w e o n ly su cceed and n ev er
fail, b u t w e d o fail m o re frequ en tly t h a n w e w ish o r hope. Like a pro­
fessional photographer, w e throw aw ay o u r b ad prints in th e d ark­
ro o m trashcan and sh ow o n ly o u r b est prints to th e public. It m a y
so m etim es b e useful to let p e o p le see o u r failures a n d w h y th e y h a p ­
pen.
T h ere are so m e clients I can't help b e c a u s e I sim p ly d o n 't kn ow
e n o u g h ; o th e r client p rob lem s m a y b e in cu rab le. A fe w years ago
there was a w o m a n w h o lived across the c o u n tr y from me. Sh e had
read so m e o f m y earlier b o o k s and liked w h a t she'd read, so sh e flew
out to see m e w ith the h o p e that I w ould b e ab le to help her. I later
found o u t that sh e was a m illion aire w h o co n sta n tly p e ru se d psy­
ch olog}' b o o k s and journals. W h e n e v e r sh e read s o m e th in g sh e liked
she'd ju m p o n a p la n e to visit th e author. Before h a v in g seen m e she
had visited m a n y fa m o u s therapists across th e country.
Adjuncts 389

A few m inu tes into m y first session w ith h er I realized that s h e was
ch ro n ica lly psych otic and that n o n e o f m y psy ch oth erap eu tic tech ­
n iq u es c o u ld cu re her. T here w ere tech n iq u es that could b e used to
h elp her, b u t sh e didn't w a n t help; sh e w an ted to b e cured. She had
ta k en all th e new an tip sy ch otic m edications, but they h ad n 't produced
a n y ch a ractero lo g ical changes. Unfortunately, sh e will p ro b a b ly on ly
h a v e h e r p rob lem rem ov ed if th e re is a m a jo r b ioch em ical b rea k ­
th ro u g h in the trea tm en t o f sch izop h ren ia; in th e m eantim e, sh e is
p r o b a b ly still flying arou n d to therapists w h o publish new books,
h o p in g th at th ey will provide h er with a n answer.
This case illustrates a p ro b lem peculiar to therapy. A lthou gh the
p u blic accepts that there are in cu rab le diseases in m edicine, such as
term in al ca n ce r or H odgkins Disease, th ey don 't accept that problem s
in p sych ology or psychiatry are incurable. Despite the public's denial,
there are clients with problem s we can't fix . W h e n w e work with these clients
w e c a n o n ly teach them s o m e skills, help th em to accept th eir prob ­
lem (see c h ap ter 12, "Treating Seriously M en tally 111 Patients.''), and
m a k e th em as co m fo rta b le as possible, b u t th e essence o f th eir disor­
d er will r e m a in th e same.
At o th e r tim es w e h a v e th e tools and th e necessary know ledge, b u t
are still n o t a b le to help b eca u se th e client will n ot allow us. This is
n o t th eir fault; they are n ot to b lam e, but th ey sab otage treatment.
O n e client was a convict. He w as in prison for h avin g com m itted
murder, and w ould not b e eligible fo r parole for m a n y years. He suf­
fered from ex tre m e c o m p u lsiv e b e h a v io r including excessive hand
w ashing, c o u n tin g his steps w h en h e w alked in th e exercise yard, and
p erform in g m e an in g less rituals for hours on end. There are m a n y cog­
nitive a n d b eh a v io ra l tech n iq u es for such problem s. There was a rea­
so n a b le c h a n c e o f h elp ing him , b u t h e w ould n't listen to an ything I
said. H e was m u ch to o angry at th e courts, th e prison, th e world, and
h im s e lf to follow m y instru ction s o r even to w ant to.
T h e p rob lem th at o u r profession faces is captured b y th e old jo k e
a b o u t therapists.
"H ow m a n y psychologists does it take to c h a n g e a light bulb?"
"Just on e , b u t th e light b u lb has to w an t to b e changed."
M a n y o f m y colleag u es h av e fo u n d this co n ce p t to b e true. H um ans
can c h o o s e to d o s o m e th in g or not to. T he c o m b in e d persuasion o f the
best therapists in th e w orld c a n n o t b u d g e a person w h o had decided
n o t to change. W e can plead with a person to practice a particular
exercise th re e tim es a d ay for 10 weeks, b u t th e person can always
think, "No. I w o n 't d o it."
390 I n t N e w H a n d b o o k o e C o g n it iv e T h e r a p y T e c h n iq u e s

O f cou rse so m e tim e s w e ju st fail, usually b e c a u s e w e a re e ith e r loo

hard or loo soft o n o u r clients. We are loo hard w h en w e put t o o m u ch
pressure on th em and ex p e ct th e m to c h a n g e too q u ick ly o r to o m uch.
C ou nselin g is a form o f en c o u ra g in g grow th, an d th e th erap ist is like
a gardener. W e can b e c o m e im p a tien t or frustrated a n d start to pull on
th e person to grow faster. C h a n g e and grow th an d h ealin g ta k e their
ow n g o o d tim e; they d o n ot o p e ra te a ccord in g to th e dictates o f eith er
th e d o cto r o r patient. It is o u r responsibility as psych ologists to weed
peoples' gard en in ord er to provide a fertile g ro u n d a n d th e n to w ait
for th e blossom o f c h a n g e to appear.
In m y exp erien ce, m ost therapists' m istakes arise from h av in g b e e n
loo easy. B eg in n in g therapists m a k e this m istak e frequently, and
u n trained c o u n selo rs do it all th e time. Therapists are peop le, an d are
con d ition ed to feel sy m p a th y for s o m e o n e in pain. B eg in n in g th era ­
pists don 't se e w hat's b e h in d th e pain, so th ey rush in and offer sy m ­
pathy and try to rescue clients from their hurt. This m ak es clients feel
b etter temporarily, and th e therapist receives gratitude, letters o f
appreciation, an d referrals.
Usually, however, this rescuing is a big m ista k e an d u ltim ately hurts
clients a great deal. T h e em o tio n a l pain that w e h u m a n b e in g s feel is
a signal or sign th a t s o m e th in g is wrong. In a sen se it is m u c h like
physical pain; it tells us that so m e b o d y part is in ju red a n d n ee d s ou r
attention. T h e pain o f a splin ter in o u r foot tells us to lo o k for the
splinter, b u t if we quickly n u m b th e pain w e m a y leave b e h in d too
m a n y splinters. Likewise, em o tio n a l pain m otivates us to find its cause.
W h e n w e rem ove the hurt w e m a k e it m ore difficult, and so m e tim e s
im possible, to find th e ro o t o f o u r pain.
T h e best ex am p le o f this typ e o f m istak e is treatin g th e alco h o lic
person. Initially societies treated alco h o lics w ith scorn and disgust
b e c a u s e society assum ed th em to b e m oral degen erates. This tactic
didn't w ork; alcoh olics c o n tin u e d drin king ju st th e sam e. Later society
treated (hem as psychologically distu rbed individuals w h o needed
e m p a th y and sy m p a th y to b o o s t th eir flagging se lf-c o n fid e n c e an d to
lessen the negative effects o f their early ch ild h o o d ; alco h o lics c o n tin ­
ued drinkin g ju st th e sam e. Next so ciety suggested th a t alco h o lics had
a m edical disease and treated th e m as m e d ica l patients. S o cie ty gave
th em drugs to lessen th eir craving, b u t th ey kept d rin k in g ju st the
same.
Today w e kn ow that these ap p ro a ch e s w ere m istakes, a lth o u g h
so m e therapists w ould still disagree. T hese previou s attem p ts en a b le d
a lcoholics to drin k m o re b y rescu in g th e m a n d not allow ing th e n a t­
Adjuncts. 391

ural c o n s e q u e n c e o f their b e h a v io r to hit them ; these treatm ents

served as a b uffer b etw e en the alcoholics' drinking and real-w orld
co n se q u e n ce s. To h elp alcoholics, therapists have found it best to c o n ­
front th e m w ith the tru th th a t they are hooked, that drink is destroy­
ing th eir families, th e ir health, an d th eir ability to b e happy, and that
th e b e st way to turn th eir lives a ro u n d is to adm it to their addiction
an d stop all use. O ften the o n ly w ay so m e alcoholics can see this truth
is to stew in their ow n m esses until they perceive what a personal
h o lo c a u st th eir drin king has produced.
T herapists h av e m a n y failures that h a v e sad dened us, but we
e n d u r e th em b e c a u s e w e r e m e m b e r th ose clients w e were ab le to
help. M o st o f the tim e o u r successes m a k e up for o u r failures.

F u rther In fo r m a tio n
W ith the ad v en t o f H M O s into the ad m in istration o f m ental health
services, th e re has b e e n in creasing need to show th e effectiveness o f
a n y b ran d o f p sy ch otherapy (Giles, 1993a, 1993b). T h e necessary and
sufficient c o n d itio n s for effective cognitive therapy have stood up well
to th ese tests (Beck, 1995; D obson, 1989; Elkin et al., 1989; R achm an,
R achm an, & Eysenck, 1997; Shea et al., 1992).
T hirteen

Cross-cultural
Cognitive Therapy

( C l ie n t s d o n 't fo rm t h e ir beliefs in isolation. T hey c o m p o s e th em

b o th from th eir ow n life ex p erien ces an d b y ad op tin g attitudes from
the b ro a d e r b e lie f system held by o th ers a ro u n d them . By lo o k in g at
clients' affiliation groups, w e usually discover that they sh a re m a n y
core beliefs with their culture.
As a result, cultural aw areness o n th e part o f th e therapist is central
to cogn itive therapy; th e therap ist m u st h av e an u n d erstan d in g o f
each client's cultu re in ord er to cou nsel effectively.
Culture d eterm in es m a n y client cogn ition s: w h at they b e lie v e and
w h at th ey reject; w h at they p erceive and w h at th ey ignore; h ow m u ch
th e y are willing to sh are with a stran ger ou tsid e th e fam ily; w h a t rela­
tion sh ip they will h av e with you, th e caregiver; w h a t valu es th ey will
co n sid er im p o rtant; w h a t style o f th erap y will b e a c ce p ta b le a n d w h at
style th ey will reject out o f h a n d ; w h a t th ey will co n sid er as th e p o s­
sible causes o f th eir em o tio n a l problem s, an d h ow m u c h effort and
w h at typ e o f w o rk th ey will b e w illing to put into th eir o w n therapy.

R e f e r e n c e G r o u ps

Principles

Clients can identify w ith the beliefs and attitudes o f m a n y different

types o f groups: cultures, races, su b cu ltu ra l groups, regions, lan g u ag e
groups, nation al states, religious affiliations, and political parties.
B ecau se th e re are so m a n y p oten tial groups, it is hard to d e te rm in e
w h y clients adop t the Bs o f o n e g ro u p o v e r another. Sociolog ists offer
Cross-cultural Cognitive Therapy 393

a n ex p la n a tio n called "reference group." It is not th e grou p that p e o ­

ple are b o r n in, grew u p in, or that o th e r p e o p le th in k th e y are in; it
is th e g ro u p with w h ich th e y identify. Thus, a client could b e an
u p p e r-m id d le -c la ss Irish C atholic from th e east coast, and m ay have
b e e n b r o u g h t u p in a liberal, d e m o cra tic hou sehold, b u t he m a y m e n ­
tally identify with an a n cien t oriental ideology that h e learn ed while
stu d y in g Zen and k u n g fu. A reference grou p is the m ental h o m e that
clients live in.

M eth o d
1. A ssem b le a list o f the grou p s th at y o u r client associates with or feels
m e n ta lly part of.
2. How does y o u r client m od el w h a t the grou p teaches?
3. List th e core beliefs o f these grou ps— th e Bs that separate them from
o th e r groups.
4. C o m p o se a chart that show s the sim ilarities b etw een these group
beliefs an d th e beliefs o f y o u r client.

E x a m p le 1. X e n o p h o b ia
A n eg ativ e a spect a b o u t m a n y reference groups is that they inspire
fear o f o th ers outside their ow n group. This fear is associated with
x e n o p h o b ia ; xenon is G reek for stranger, and plw bia derives from the
G reek phobias, m e a n in g fear. Together th ey signify an exaggerated and
persistent dread o f o r aversion to foreigners and strangers. Although
it m a y se em a trivial fear, it is significant. X en o p h o b ia is o n e o f the
m ost c o m m o n cultural fears, and certainly o n e o f th e m ost damaging.
O u r clients h av e reported m a n y instances o f b ein g su b jected to
o th e r people's x e n o p h o b ia . East coast college stu den ts h av e b e e n told,
"You w on't learn a n y th in g in the sch o o ls out west. Education out there
is barbaric. T h ere is no culture west o f the A llegheny Mountains."
O u r clients from th e w est h a v e b e e n told, "People from the east
co a st are intellectual sn ob s, p om pou s, stuffy, effete p eople w h o are
totally disingenuous."
In th e sou th, x e n o p h o b ia takes th e form of, "D am n Yankee carpet­
baggers. G o b a ck w ere you c o m e from , if y o u know what's g o o d for
you," w h ile n o rth e rn clients are told that e v e ry b o d y in th e sou th is a
bigot, a hick, o r a d u m b redneck.
In Texas, o u r clients h e a r x e n o p h o b ia expressed as Texas against the
o th e r 4 9 states, or "Tex'ns vs. the Feds," as they put it. In Colorado, m an y
394 T h e .N e w H a n d b o o k o i .C o g n it iv e T h e r a p y T e c h n iq u e s

people dislike Texans, o r flatlanders, as they call th e m (a n y b o d y not

from m o u n ta in o u s terrain). In W ash in g to n an d O regon, s o m e p eople
have b u m p e r stickers saying, "O u t o f Staters G o H ome!" a n d visiting
Californians are w arned not to drive w ith California license plates.
Sim ilar tales can b e told o f x e n o p h o b ia in v o lv in g c o u n try o f origin,
religion, political party'— it can b e found everyw here. As therapists w e
could d iscou n t clients' x e n o p h o b ia as a n o rm a l pride for p e o p le like
them selves, a natu ral n o n p a th o lo g ical ro o tin g for th e h o m e team . But
m o n stro u s d a m a g e m a y lu rk inside this self-pride. T h e others, th e
strangers, the foreigners, th e "them s" are perceived as evil, sinister, and
m alevolent. This produces an alm ost spiritual rejection o f p e o p le w h o
act and ap p e a r different. From this c o n te m p t spring th e psy ch ological
roots o f prejudice, bigotry, an d d iscrim in ation that h av e cau sed the
lion's share o f m iser)' on o u r planet. Helping clients to recognize
x e n o p h o b ia (their ow n and others') as a co re fear can aid in creating
a m ore fair-m in d ed and b ec a lm ed b e lie f system.

E x a m p le 2. C ulturally A p p rov ed D iag n osis

T h e cultural referen ce grou p also teach es clients w h at types o f e m o ­
tional p rob lem s are a c ce p ta b le to have. It m a y b e a c ce p ta b le to have
an ad ju stm en t reaction to adult life b u t co n sid e ra b ly less a c ce p ta b le
to have a sexual disorder o r a m a jo r psychotic episode. T h e disorders
that are cultu rally approved h a v e ch an ged th ro u g h o u t th e years as
each d ecad e has p rod uced its ow n diagnostic fads.
In the late sixties and early seventies m a n y o f o u r clients suffered
from w hat can b e called existen tial anxiety. T hey c o m p la in e d a b o u t
th e lack o f m e a n in g in life. T hey so u g h t an sw ers to q u estio n s like,
"W h y am I here? W h a t is th e p u rp o se o f life?" M a n y had lost trust in
traditional institutions such as g o v ern m en t, family, and religion, and
had c o m e to th erapy b e c a u s e th e y felt b ew ild ere d — "drifting in a n o n ­
sensical cosmos," as so m e put it. As a result th ey often delved into
mystical religions and cult grou p s to provide so m e se n se o f m ean in g.
In the m iddle a n d late seventies o u r clients c o m p la in e d o f havin g
relationship difficulties. Either th eir relation sh ip s w eren 't successful or
they had n o in tim ate relationsh ips at all; clients c o m p la in e d o f lo n e­
liness and lack o f intimacy. As radical c h a n g es w ere o c cu rrin g in m a le -
fem a le roles, clients were co n fu sed a b o u t w h a t m ascu lin ity and
fe m in in ity were, and their relationsh ips suffered for this con fu sion .
In the early an d m id d le eighties clients' p ro b lem s ch an g ed again.
Clients w ere less c o n c e r n e d a b o u t lack o f m e a n in g in life o r lack o f
Cross-cultural Cognitive Therapy 395

p erson al in tim acy t h a n th ey w ere a b o u t failing. "W ouldn't it b e hor­

rible if I w asn't successful?" They w ould ask. T hey were terrified o f not
o w n in g th e right kind o f cars o r not getting into th e right M.B.A. pro­
gram s. For th e se clients, success was interpreted as havin g money,
power, an d m aterial goods.
In th e n in etie s m a n y o f o u r clients w ere expressing a type o f fear o f
disapproval; clients fear others w on't like th em ; th ey are afraid their
fa ca d e is n ot g o o d e n o u g h and that p eople m ay see the real persons
b e h in d th e mask. S o m e exam p les o f their co n ce rn s are: "I m ay not
im press o th ers en o u g h . I m a y em b arra ss myself. It would b e terrible
if p e o p le didn't approv e o f m e an d respect me."
W h e n o u r clients are asked w h ich o f the following choices they pre­
fer— k n ow led ge o r th e a p p e a ra n ce o f know ledge; cou ra g e or the
a p p e a ra n ce o f co u rag e; a c h ie v e m e n t o r the a p p e a ra n ce o f achieve­
m e n t; in tim acy o r th e a p p e a ra n ce o f intimacy'— a surprising n u m b e r
o f p e o p le c h o o s e th e appearances. T h ey are em barrassed b y this, but
defen d th em selv e s b y arguing, "W hat does it m atter if you have these
things b u t n o o n e recognizes that y ou have th em ? You won't gel any
b e n e fit from them."
Life revolves in cycles; in time, there m a y b e a great in crease in
clients again seekin g help for existential anxiety. T h ey will com p lain
a b o u t th e lack o f m e an in g in life. T hey will seek answ ers to questions
like, "W h y a m I here? W h a t is th e p u rpose o f life?" M a n y will h av e lost
trust in trad itional institutions su ch as g o v ern m en t, family, and reli­
g io n and c o m e to th erapy b ec a u se they feel bew ildered— drifting in a
n o n se n sic a l cosm os. As a result th ey will delve into mystical religions
and cult grou p s to provide so m e sen se o f m eaning.

C om m en t
M a n y clients m ay turn their x e n o p h o b ia against them selves. They
b la m e th em selv e s for b e in g part o f the "w rong" grou p s (ethnic, racial,
class, gender, cultural, generation). Such rejection can create an inter­
nal w ar with devastating con seq u en ces.
The cogn itiv e solu tion to x e n o p h o b ia , w h e th e r it is directed outside
ag ain st others, or inside against self, is to sh o w th a t it is based on the
logical fallacy o f overgeneralization. A lthou gh cultural groups may
h a v e s o m e c o m m o n traits, th e w ith in -g ro u p varian ce is alm ost always
as large as the v a ria n c e b etw e en groups. T herefore saying that all Xs
sh a re a certain characteristic is a sy m p to m o f em o tio n a l con d ition in g
rath er th a n a statem en t o f fact.
396 T h e N lw H a n d b o o k o i C o g n itiv e T h e r a p y T e c h n iq u e s

Not o n ly d o client problemSvrun in fads b u t th e m o st p o p u la r treat

m ents also g o in cycles. In th e c o u rse o f m y practice I h a v e seen th e
w a x an d w a n e o f m a n y treatm en ts: tra n scen d e n tal m ed itation, prim al
scream , existential analysis, tra n sa ctio n al analysis, n eu ro lin g istic pro­
g ram m in g, Rolfing, EM DR, dialectics, and m a n y others.

F u rther In fo r m a tio n
T he original a n d m o re c o m p le te v e rsio n o f th e x e n o p h o b ia issue
c an b e fo u n d in m y new sp ap er article (M e M ullin, 1995).
T he principle o f e th n o c e n tr ism is a m a in sta y o f so cio lo g ica l theory'
d ev elo p ed b y o n e o f th e fou n d in g fathers o f sociology, G ra h a m S u m ­
ner, in 1906. T he co n ce p t reveals itself in tw o ways: the proclivity for
p e o p le to ju d g e their ow n g ro u p as the reference for all o th e r c o m ­
parisons, a n d th e disposition to b eliev e that o n e 's o w n referen ce
g rou p is su p erio r to all o th ers (Sum m er, 1906; Sum m er, Keller, & Davie,
1927). M arsella has d o n e extensiv e w ork o n e th n o c e n tr ism in p articu ­
lar and cro ss-cu ltu ra l c o u n s e lin g in gen eral (Marsella, 1984, 1997,
1998a, 1998b; Marsella, Friedman, Gerrity, & Scurfield, 1996).

C u lt u r a l Ca t eg o r ies

Principles

T h e culture n ot o n ly instructs clients o n h ow to re s p o n d to p e o p le

outside o f their referen ce group, it also directs th e m o n h o w to v iew
them selves.
Clients m ain tain a certain se lf-d ecep tio n a b o u t th eir cultu re's in flu ­
en ce o n them . They have difficulty recognizin g that their cu ltu re
taught th em h ow to lo o k at the world, and that th eir cu ltu re taught
th em to th in k o f o th e r cultures as alien, fo u led -u p , or m uddled. T h ey
b eliev e that the way th eir ow n cu ltu re sees th e w orld is the w a y the
world really is, that their cultu re has th e o n ly correct w ay o f lo o k in g
at life.

E x a m p le 1: D yirbal C ateg ories

Women, Fire and Dangerous Things, w ritten b y Lakoff (1985), sh ow s h ow
clients' view s o f th e world are relative to th eir culture. T h e b o o k is full
o f stories a b o u t th e langu age o f different societies, and it ex p la in s how
Cross-cultural Cognitive Therapy

la n g u a g e forces p eople to see and feel different things. A central story

in th e b o o k is a b o u t th e Dyirbal A ustralian ab origin al tribes— the
b o o k 's title co m es from this story.
In th e Dyirbal la n g u a g e every n o u n is preceded by o n e o f fou r cat­
egories, a n d in essen ce ev ery th in g in the u n iv erse can b e divided into
th ese categories. Each category has a n am e: Bayi, Balan, Balam , o r Bala.
W h e n e v e r th e Dyirbal n a m e an ything , they in trod u ce it by identify­
ing the ca te g o ry that th e o b je ct falls under. These categories are m ore
th a n linguistical; th ey also sh ow h ow th e sp eak er relates to th e object,
so th a t different em otio n s, b eh av io rs, and values are associated with
each group. For ex am p le, th e cu ltu re categorizes the o b jects in figure
13.1.
M a n y w estern ers w ould classify these item s into th e follow ing cat­
egories: (1) Natural Phenom ena: rainbow s, rivers, th e sun, stars, the
m o o n , and fire; (2) A nim als: snakes, parrots, fireflies, hairy M ar)' grubs,
crickets, honey, echidnas, kan g aroos; (3) M an m ad e Goods: spears; (4)
H um ans: m en, w o m en . T hese grou p in g s reflect W estern logic rather
th a n Dyirbal culture. T he correct Dyirbal categories are:

Bayi: b o o m e ra n g s, m en, kangaroos, n o n p o iso n o u s snakes, rain­

bow s, a n d the m oon . This category often produces an anim ated,
excited feeling in th e listener.
Balan: rivers, w o m en , p o iso n o u s snakes, stars, lightning bugs, fire,
th e sun, platypus, parrots, echidnas, spears, and the hairy M ary
grub. Item s in this category are o ften feared.
B alam : c o n s u m a b le item s like honey, fruit, and ed ible leaves. Balam
item s are often desired.
B ala: a n y th in g n ot in the a b o v e three groupings. These items the
Dyirbal will often feel neutral about.

Dyirbal p eople categorize in this way b eca u se o f th eir culture. M en

a n d th e m o o n are in the first c a te g o iy b e c a u s e in Dyirbal mythology,
th e m o o n and the su n are h u s b a n d and wife and m en are descended
from th e m oon . Sin ce m e n use b o o m e ra n g s to h u n t kangaroos, b oth
are placed here. R ain b ow s are included b e c a u s e the souls o f m en w ho
die as h ero e s turn into rainbows.
W o m e n and th e sun are b o th in the se co n d category b ec a u se all
w o m e n d escen d from th e sun, w h ich is considered female. Fire, poi­
so n o u s snakes, an d th e hairy M ary g ru b sting like the sun so they are
all included. Surprisingly, spears also fall into this category b ecau se
this en tire category' includes the co n ce p t o f d ang erou s things (thus the
 I h e N tw H a n d b o o k o f C o g n it iv e T h e r a p y T e c h n iq u e s

River Boom erang Hairy M ary Grub

Parrot N onpoisonous Snake Sun Man

Woman

Echidna

o
Platypus Stars Kangaroo Cricket

F IG U R E 1 3 .1 O b je c t s c la s s if ie d in t h e D y ir b a l la n g u a g e
Cross-cultural Cognitive Therapy

title o f th e b o o k — Women, Fire, and Dangerous Things). Rivers are included

b e c a u s e w a te r from rivers puts out fires. Stars and lightning bugs
sh in e like th e sun, so they are included. Parrots and m a n y o th e r birds
are b elie v ed to b e th e spirits o f h u m a n fem ales. And crickets? In Dyir-
b a l m yth, crickets are old ladies.
M o d ern , industrialized W estern logic would h av e difficulty explain ­
ing th ese categories. U n d ersta n d in g th e m at all requires that w e set
aside th e logic sy stem that w e h av e b e e n cultu rally b o r n to. Even in
a tte m p tin g to do so, m o st W esterners w ould still th in k th e categories
are cockeyed, th e prod uct o f primitive, u n ed u ca ted brains. M an y
w ould in co rrectly b e lie v e that th e categories are just prim itive su p er­
stitions, that ou rs are th e o n ly correct ones.
T h ere are no n a tu ra l or correct categories. Theirs are as g o o d as
ours. O urs se em correct to us b e c a u s e we grew u p in o u r ow n culture
a n d w e th in k o u r view o f the world is the o n ly natural one. The sam e
is true o f th e Dyirbal.
H erein lies the great insight in Lakoff's b o o k and the reason it can
b e so im p o rtan t to therapists. T here are no natu ral or correct w ays o f
look in g at th e world. Clients have learned to perceive things in certain
ways b e c a u s e th eir cu ltu re has taught them to d o so. Because differ­
en t societies teach different categories, th ere are n o a priori or neces­
sary grou p in g s— th ere is n o natural way o f lo o k in g at things; all
cu ltu rally dictated categories are arbitrary. Clients' cultures, their soci­
eties, and langu ages all teach th em h ow to view things.
T h e lan g u ag e th a t clients use is m etap horical in nature. In other
words, th ey u n d erstan d o n e e x p e rie n ce b y co m p a rin g it to another.
These m e ta p h o rs are cultural and reveal so m e o f th e m ost fu n d a m en ­
tal values o f th e society th ey live in. Clients' m etap h ors tell them what
to see, h ow to c o p e with th e world, and how to interact w ith o th er
people. O ften clients upset them selves u n n ecessarily b y implicitly
accep ting an ou td ated m e ta p h o r that m isrepresents them. So m e
words, such as bipolar, m a n ic with c a tato n ic features, b u lim ia nervosa,
o r p aran oid sch izophrenic, can h a u n t clients for th e rest o f their lives.
It is important that w e as therapists help clients to exam ine the core cat­
egories that reside at the base o f their cognitions and to understand that
there are other ways o f looking at the world and themselves (Duhl, 1983).

M eth o d
1. H ave y o u r clients pick a p erson al trait they feel m ost upset about.
2. L oo k in a g o o d thesau ru s and collect all o f th e m etap hors associ­
400 T h e N f w H a n d b o o k q f C o g n it iv e I eieraev J E e c e m q u e s .

ated w ith this trait. Pay particular a tten tio n to slang expressions.
3. S ee w h e th e r the m eta p h o rical descriptions a ccu rately d e sc rib e y o u r
clients' p rob lem s or w h e th e r th ey are sim p ly cultural a n a ch ro n ism s.

E x a m p le 2 : One Client's C ateg ories

O n e o f m y clients picked the word "inferior" as his cen tral trait. He
look ed th e w ord up in a thesau ru s and picked th e follo w ing phrases
as th e m ost accu rate description o f his feelings.

C a m e up short Lightweight
Lower th an Lowly
U nd er Less than
Sm all p o tato es Puny
Bargain b a se m e n t T w o -b it
Sm all tim e M ick ey m o u se

This client associated "inferior" w ith th e m e ta p h o r o f sh o rtn ess and

sm allness b ec a u se he perceived th a t th e size o f a m an is associated
with his ability to defen d and protect w o m e n ; his cu ltu re h ad tau g h t
h im that a sm all or sh o rt m ale is less cap a b le o f d o in g this. This
m e ta p h o r was cou n tered b y h elp in g h im recognize th a t th e in v e n tio n
o f th e b o w and arrow, th e slingshot, guns, b o m b s, a u to m a tic w eap on s,
and n u cle a r b o m b s h av e blu rred th e im p o rta n c e o f m a le size to a
great extent. His favorite c o u n te r phrase was, "I will protect you from
those nasty n u cle ar w eap on s, m y dear."

E x a m p le 3 : A n o th er Client's C ateg ories

A client in M elb o u rn e, Australia, was a n a g o r a p h o b ic w'ho suffered
co n sta n t p an ic attacks th at cau sed h er to h id e in h e r h o u se a n d not
travel. This client, w h o m I'll call M artha, had not traveled b e y o n d a
h a lf-m ile radius o f h e r h o u se for 10 years. Her g ra n d ch ild ren lived in
a n o th e r state, and sh e o n ly saw th em o n th o se rare o c ca s io n s w h e n
th e w h o le family could afford to visit her.
After a few sessions w e fou n d the particular co g n itio n th at w as the
cause o f M artha's panics. S h e b elie v ed that th e e m o tio n s o f a n g e r and
stress w ere d angerou s, and so to protect h e rs e lf fro m th ese feelings she
had created a narrow e m o tio n a l safety zone. I f h e r e m o tio n s e v e r rose
a b o v e th e zone, sh e w o u ld panic. To c o p e s h e h a d to h id e in h e r h o u se
a n d avoid all situations that m ight p ro d u ce th e se feelings.
W h at was difficult to d e te rm in e was w h y s h e b elieved this thou ght.
Cross-cultural Cognitive Therapy 401

W h y did sh e view feeling a n g e r a n d stress as so dangerous? We could

find n o tra u m a tic ev en t in her history that could have caused such
fear, b u t Lakoff's b o o k provided a clue. It suggested that she might
ha v e sim p ly categorized these e m o tio n s as d ang erou s b e c a u s e o f her
cultural back grou n d . Her cultu re m a y have labeled these feelings in
su ch a w ay th a t sh e associated d a n g er with them.
To ex p lo re this idea sh e d escribed in detail everything sh e had b e e n
ta u g h t a b o u t feeling e m o tio n s su ch as anger, fear, stress, sadness, rage,
o r terror.
S h e had grow n up in an u p p er-class British family, and had
a tten d ed private prep schools based o n the continental m odel. In her
cu ltu re it was con sid ered low class to sh ow a n y feelings strongly. Dis­
plays o f e m o tio n were considered petty b o u rg eo is and indicated a lack
o f breeding. T hese are the sy n o n y m s sh e had learned describing
stro n g em otio n s:

Anxiety: losing control, on te n d e r-h o o k s, out o f one's head,

hysterical, b erserk; sh ak in g like a leaf, overw helm ed, ab o u t to
explode, falling to pieces
Anger: b low in g you r top, losing it, exploding, flipping you r
wig, freaking out, h a v in g a fit, hitting th e ceiling, h aving a h em ­
orrhage, b lo w in g a gasket

T h ese were m o re th a n ju st phrases; they w ere th e ways sh e viewed

em o tio n s, a n d th ey prescribe how sh e would ex p erien ce having these
feelings. Like th e e x a m p le o f th e Dyirbal, the core categories prescribe
th e glasses th ro u g h w hich sh e saw th e affective world. They w ere basic
reflexive reactions that M arth a had learned from the tim e sh e was
you ng, and sh e did not b eliev e th at em o tio n s could b e perceived in
a n y o th e r way.
H er d efin ition s sh ow how she categorized em otio n s— sh e perceived
th em as en ergies inside containers. A nxiety and an ger were the
energy, w h ile h er b o d y w as the container, and if em o tio n a l pressure
b e c a m e to o strong, th e c o n ta in e r could explode. Descriptions like,
"falling to pieces, explod ing, b lo w in g a gasket, hitting th e ceiling,"
d e m o n stra te d h e r perception. S h e was afraid o f em o tio n ally explod­
ing, so w h e n e v e r s h e felt the slightest fear or an ger sh e b e c a m e terri­
fied th a t th e feeling w ould build to an u n co n tro lla b le level and she
w ould g o in sa n e o r h av e a nerv ou s breakd ow n. In h e r m in d she
w ould o n ly b e protected if sh e kept these e m o tio n s in a narrow safety
z o n e ; s h e had to co n tro l h e r e n v ir o n m e n t c o m p le te ly to keep her
e m o tio n s from growing.
To help M arth a w e had to c h a n g e th e way her langu age categorized
402 T h e N e w H a n d b o o k o f Co g n it iv e T h e r a p y T e c h n iq u e s

her em otio n s. If w e ch an ged h e r m etaphor, m a y b e w e c o u ld rem o v e

her panics.
I told her that h u m a n b e in g s don 't h a v e gaskets that can b e b lo w n .
N o b o d y hits ceilings, an d th e tops o f o u r h ead s don 't e x p lo d e w h en
w e get upset. This description is ju st an old m e ta p h o r from a tim e
w h en p e o p le were u n en lig h ten ed a b o u t h u m a n e m o tio n s o r h u m a n
physiology. A m o re useful w ay to lo o k al h e r e m o tio n s w as to th in k
o f an electrical circuit. Either th e sw itch is o n o r it is off, b u t the en erg y
doesn't b u ild up inside o f h e r a n y m o re th a n th e en e rg y bu ild s inside
a television w h e n sh e shu ts it off. S h e didn't h av e to fear her em o tio n s;
sh e ju st had to feel them.
It w asn't easy to c h a n g e M a rth a's language. These categories w ere
part o f her b asic m od el o f the world, so sh e held o n to th em tightly.
O th er p e o p le were co n sta n tly reinforcin g h e r percep tion s b y su ggest­
ing, "You shou ld let y o u r a n g e r out b e fo re you explode," o r " D o n ’t let
jealou sly built u p inside o f y ou or you could crack."
O ver tim e s h e w as ab le to c h a n g e h er language. S h e sh ifted h e r
fram e o f reference and started to see e m o tio n s differently. W h e n sh e
accom p lish ed this, h e r panics left. S h e accep ted fear an d a n g e r as a
norm al h u m a n process— distressing at tim es, b u t n ot d an g erou s. Sh e
started to extend h e r e m o tio n a l safety z o n e so that sh e co u ld e x p e ri­
e n c e th e full ran ge o f her em o tio n a l life. It to o k tim e, b u t o v e r m a n y
m o n th s sh e shifted h e r categories an d felt m o re and m o re w h ile fear­
ing h e r feelings less a n d less. S h e started to cross h e r o n e - m i le terri­
tory; the last I heard sh e has b e e n visiting h e r g ra n d ch ild ren regularly.

C om m en t
If w e accept Lakoff's co n ce p t that th ere are no natural categories, it
follows th a t o n e cultural v iew is not n atu rally su p erio r to another. As
therapists w e need to m ain tain cu ltu ra l-relativ e position s and not
reject o u r client's view sim p ly b e c a u s e it is different from o u r ow n. We
do, however, have the o b lig atio n to sh o w o u r clients th a t a lth ou g h
th eir categories m ay b e eq u a lly "true o r false" they m ay n o t b e eq u a lly
useful to them . U ltim ately th e clien t will d ecid e w h ich v iew is m ost
helpful.

Further In fo r m a tio n
Lakoff has w ritten several m a jo r w orks that discuss his c o n c e p ts in
Cross-cultural Cognitive Therapy 403

detail (Lakoff, 1983, 1985, 1990; Lakoff, Taylor, Arakawa, & Lyotard,
1997).
S e m in and Fiedler h av e explored the fu n ctio n s o f linguistic cate­
g ories o n people's b eh a v io rs (Sem in & Fiedler, 1988, 1989, 1991).
The ab ility o f a culture's ev alu ation s to create e m o tio n s in m e m b e rs
has b e e n studied ex ten siv ely (see K itayam a & M arkus, 1994; Marsella,
1984; M arsella, Friedman, Gerrity, & Scurfield, 1996; Russell, M anstead,
W allen k am p , & Fernandez-D olls, 1995; Scherer, 1997).

C u lt u r a l B e l ie fs

Principles

Behind m a n y client p rob lem s are a few core beliefs and a few key
attitudes th a t ca u se m ost o f th e dam age. O ver th e years cross-cu ltu ral
research ers h av e g a th e re d lists o f th ese beliefs and have found that
m a n y o f th em originate from th e cultures that clients grow up in. If
therapists are to u n d erstan d w h y so m e beliefs are so dam aging, we
first n eed to u n d erstan d th e cultures th a t give birth to them.
People all o v er th e world sh a re certain superstitions. T hese beliefs
are not co n fin e d to o n e c o u n try o r o n e culture; therapists h e a r these
distortion s w h erev e r they travel. No o n e grou p is m ore o r less rational,
healthy, or en lig h ten ed th an a n o th e r b e c a u s e o f their beliefs; all cul­
tures h av e th ese distortions. T h e o n ly difference a m o n g them is that
different cultures have different types o f superstitions.
A m a jo r sou rce o f cultural superstitions is attribution theory— the
ex p la n a tio n s that a cultu re gives to ex p la in w h y p eople act th e way
th ey do. Different cultures develop different explanations. W h en
clients search fo r a n ex p la n a tio n for their ow n o r others' b eh av io r
th ey u su ally c h o o s e th e culture's attrib u tion first. For exam ple, United
States cu ltu re h a s offered a variety o f ex p la n a tio n s for why people
en g a g e in certain behaviors. Here are a few that have b e e n suggested:

Behavior Attribution

h o m e le ss laziness
crim inal acts low self-esteem
colds lack o f v itam in C
in san ity b ad parenting
AIDS God's p u n ish m en t
 T h e N f w H a n d b o o k qf_ C o g n it iv e T h e r a p y ^Te c h n iq u e s

M eth o d 1 v

Give clients th e follow ing su rv ey and a sk th e m to rate th eir answ ers

o n a Likert scale from "Stron gly Agree" to "Stron gly Disagree."

I m u st h av e e v e ry b o d y like me.
M a k in g m istakes is terrible.
M y em o tio n s can't b e controlled.
I shou ld b e terribly w orried a b o u t th re a te n in g situations.
Self-d isciplin e is to o hard to achieve.
I must d ep en d on others.
M y ch ild h o o d will alw ays d o m in a te me.
I can't stand th e w'ay o th ers act.
Every' p rob lem has a perfect solution.
I sh ou ld b e b e tte r t h a n others.
If others criticize me, I m ust h a v e d o n e s o m e th in g w rong.
I can 't c h a n g e w h at I think.
I sh ou ld do ev eryth in g perfectly.
I h a v e to help ev ery o n e w h o needs it.
I m u st n ev er sh ow a n y w eakness.
H ealthy p eople don 't get upset.
There is o n e true love.
I shou ld n ev er hurt a n y o n e, ev en b y accident.
There is a m ag ic cu re for m y problem s.
Strong p eople don 't ask fo r help.
I can do things o n ly w h en I'm in the m ood .
I a m always in the spotlight.
It's others' responsibility to solv e m y problem s.
People o u g h t to d o w h a t I wish.
G ivin g up is th e b est policy.
I need to b e sure to decide.
C h an ge is u nnatural.
K now ing how m y p rob lem s got started w h e n I w as y o u n g is
essential to solv ing them.
E veryb od y shou ld trust me.
I sh ou ld b e ha p p y all the time.
T here is a secret, terrible part o f m e th a t co n tro ls me.
W orkin g o n m y p rob lem s will hurt me.
T h e world o u g h t to b e fair.
I a m not resp o n sib le for m y behavior.
It is always b e st not to b e genuin e.
Cross-cultural Cognitive Therapy 405

• It is d a n g ero u s to feel em otions.

• People sh o u ld n 't act th e w ay they do.

2. Review y o u r clients' an sw ers an d ask t h e m w h ere th ey learned the

belief. Try to help th em find th e exact cultural source for each b e lie f
th ey agree o r strongly agree with.

E x a m p le
O n e particular cu ltu ral fiction th at seem s to ca u se a great deal o f
p ro b lem s for m a n y clients is th e "o n e true love" fantasy. Relationships
are difficult en o u g h , b u t th ey b e c o m e a lm ost im p o ssib le to navigate
w h e n a client's o n ly m a p is a cultural fable. O n e o f th e oldest fables
a b o u t love c o m e s from the orient. M a n y clients h av e described a ver­
sion o f this tale.
T h e tale describes h o w m e n a n d w o m en were not separate crea­
tures in a n c ie n t times, b u t w e re co m b in ed in a single h u m a n being.
O n e d ay an evil d e m o n b e c a m e angry w'ith God, and m agically split
th e h u m a n so u l into tw o parts— m ale a n d female. He th en hurled
th ese divided parts in to th e north w'ind, scattering th em across the
earth. From th a t tim e o n all m e n and w o m en had to spend the rest o f
th eir lives trying to find th eir m issing half. There was on ly o n e ideal,
o n e perfect m atch fo r each person. If th ey found their missing half,
th eir o n e tru e love, th e y w o u ld b e c o m e w h o le again and eternally
blissful. If not, th ey w ould forever w a n d er the world searching— for­
lo rn and in con solable.
This fa b le teach es a d am a g in g m oral and causes w orlds o f problem s
b e tw e e n m e n and w o m en . M a n y coup les reject goo d potential mates
b e c a u s e th e y find a faint b lem ish in them. In their m ind s their o n e
true love c a n h av e n o flaws. They can g o th ro u g h scores o f relation­
ship s lo o k in g for th e perfect mate, and m ay reject prom ising partners
sim p ly b e c a u s e o f an im perfection. W h e n th ey discover th e futility o f
th e ir search, th ey m a y find o u t that it's to o late to find a n y o n e at all.
T h e fa b le m a y also u n derlie so m e m arital problem s. In so m e cul­
tures o v e r h a lf o f the m arriages ultim ately end up in divorce. Typically
th ese relationsh ips start o u t well. A y o u n g m a n and yo u n g w o m en
d ate each o th e r and fall in love. Initially ev eryth in g is ro m an tic and
ex citin g b u t th en after a few years th e relationsh ip loses its excitem ent;
th e c o u p le gets b o re d and they b e c o m e disillusioned.
W h ile th e r e m a y b e m a n y re a so n s m arria g e s b r e a k d o w n — loss o f
novelty, s e x u a l b o r e d o m , in -la w p ro b le m s, fin a n c ia l insecurity, loss
o f a n e x te n d e d fa m ily sy stem , e a s y divorce, in fid elity an d so o n —
406 T h e N e w H a n d b o o k o f C o g n it iv e T h e r a p y T e c h n iq u e s

th e fa b le m ay lu rk b e h in d m a n y o f th e s e fa ilu r e s .
T h e rea so n that this b e lie f is so d a m a g in g is th a t it teach es the
y o u n g to ex p ect a lot from m arriage— a perfect u n io n , o n e true love,
b e c o m in g w h o le a n d com plete.
T h e fab le h a s spread to all cultures, w ith th e o n ly difference lying
in the definition o f "perfect." An A m erican m a y d e fin e p erfection in a
m arriage as w ealth an d high status, w h ile an A u stralian m a y m ean
co m p a n io n sh ip . To a Pacific Island er a perfect m arriage m a y refer to
serenity and babies, w h ile m a n y o th e r cultures m ay ex p e ct p e rm a n e n t
rom ance.
E x pectation s clim b m o u n ta in s w h ile reality sits th ere trying to put
on its socks. T h e reality o f m arriage crash es dow n o n th e " o n e true
love" fable: th e A m erican co u p le hits an e c o n o m ic recession ; th e Aus­
tralian wife en co u n ters m ale "m ateism "; the Pacific Islan d er discovers
that it is folly to m e n tio n seren ity a n d b ab ies in th e sam e sentence.
The fable has spaw ned m a n y o th e r superstitions. A m o n g th em are:

• In ord er to b e h a p p y y ou need y o u r sp o u se to love y o u all th e time.

• W h e n y o u r sp o u se m akes a m istak e you sh o u ld criticize a n d b la m e
them.
• In a g o o d m arriage you will o n ly h a v e sexu al desires for y o u r
spouse.
• You shou ld b e co n ce rn ed a n d upset w h e n y o u r m arriage is not
ideal.
• T he sp o u se causes m arital problem s.
• Successful m arriages sh ou ld solv e o r at least greatly red u ce the
em o tio n a l p rob lem s you had b efo re y ou married.
• Loving each o th e r is all you n ee d to h av e a g o o d marriage.
• You shou ld love steadily all the time.
• A g o o d sp o u se puts u p w ith a n y p ro b lem their p a rtn er has— a lco­
holism , b ad temper, etc.
• S im u lta n e o u s orgasm s are n ecessary for a g o o d sex life.
• W h e n y o u r sp o u se treats you badly, it's y o u r fault for not b e in g a
g o o d e n o u g h partner.
• It is g o o d for the partners to b e totally e m o tio n a lly d e p e n d e n t on
e a c h other.
• G o o d m arriages d o n 't h a v e m a jo r problem s.
• Your partn er sh ou ld kn ow y o u r n ee d s an d desires w ith o u t having
to ask.
• If you love each o th e r en o u g h , you sh ou ld n 't h av e to w o rk o n y o u r
relationship.
Cross-cultural Cognitive Therapy 407

• Sp ouses m u st act th e way their partners w ant them to act in order

to h av e a h a p p y marriage.
• Love is a m ysterious thing and no o n e kn ow s w hat it is.
• C hildren alw ays m a k e a m arriage happier.
• If you n e v e r argue, it m e a n s you h av e a goo d marriage.
• Love and m arriage go together.
• W h e n th e r o m a n tic feelings fade it m e a n s there is som eth in g w rong
with th e m arriage.
• In g o o d m arriages coup les do ev eryth in g together.

So w h a t ca n clients do to im prove their intim ate relationships? I

often tell th em it's b est to r e m e m b e r w h a t Jam es Cagney said o n the
o c c a s io n o f his fiftieth w edd ing anniversary. T he press had noted that
it w as u n u s u a l for a m arriage to last fifty years, particularly in Holly­
w ood, w h ere lo n g -la stin g fidelity is u n co m m o n . W h e n reporters
ask ed h im w h y his m arriage was so successful, C agney answ ered sim ­
ply, "W e didn't ex p ect to o much."

M eth o d 2
1. Focus o n a client's particular A -C situation.
2. D iscover w h a t h e or sh e believes is th e cause o f th e problem in the
situation.
3. Help y o u r client find the sou rce o f th e attribution. Did it c o m e from
th e cultu re or is it b ased o n the client's ow n experience?
4. D escrib e h ow a n o th e r cu ltu re m ig h t attrib u te a different cause in
th e s a m e situation.

E x a m p le
S o m e a ttrib u tio n s are crucial to a culture. A m o n g th em is th e attri­
b u tio n a b o u t w h o is to b la m e w h en so m eth in g goes wrong. T here are
several p ossib le cultural explanations.

Self vs. Others

"Was I the cau se o r was so m e o n e else respon sible?" T he answ er to
this q u e stio n m ay d e te rm in e w h e th e r a client will go through life with
guilt. In certain cultures, child ren o f divorced parents o ften m isat-
tribu te th e ca u se o f th e divorce and c o n clu d e that they w ere th e cause.
From a n adult poin t o f v iew th e child's m isin terp retation is a sto u n d ­
ing, b u t from th e child's view it is qu ite natural. O n e client th o u g h t he
had cau sed his parents to d iv orce b eca u se h e h ad n 't kept his room
 T h e N e w H a n d b o o k o e . C o g n it iv e T h e r a p y T e c h n iq u e s .

d e a n . A n o th e r re m e m b e r e d th in k in g h er m o m left b e c a u s e s h e was
co n tin u a lly soiling h e r dresses.
Thou gh th e attrib u tions in this e x a m p le are not n ecessarily cultu r­
ally inspired, they are p ertin ent b e c a u s e th ey d e m o n str a te th a t th e
attribu tions that clients assign w h en th e y are ch ild ren d o n 't c h a n g e
w h en th ey b e c o m e adults. O n c e a c o n clu sio n is reached at an early
age, it is tucked away a n d con sid ered to b e a b asic truth, n o t su b ject
to further review. T h e result is that m ature, intelligent adu lts can b e
r u n n in g c o rp o ratio n s and raising th eir families, b u t still th in k in g in
the dark recesses o f their b ra in s that th ey w ere rotten kids an d that
th eir m e sse d -u p ro o m s caused their parents' divorce.

H u m a n vs. E n v i r o n m e n t a l
People from o th e r c o u n trie s are often perplexed as to w h y th e re are
so m a n y lawsuits in Am erica. T h ey a sk w h y w e su e so m uch.
T he an sw er is com plex. T h ere are m a n y e c o n o m ic and social rea­
sons, b u t a n o th e r a n sw er m a y b e an A m e rica n cultural attribu tion.
W h e n bad things h app en , the A m e rica n cu ltu re often attrib u tes the
c a u se to h u m a n error. T h ere seem s to b e a core attrib u tio n th a t s o m e ­
o n e has to b e to blam e. Not som ething, b u t som eone. M a n y A m e rica n s
do not accept accidents, b ad luck, acts o f God, o r an indiv idu al's b ad
ju d g m en ts as accep ta b le causes. T h e b e lie f is that natural accid ents
don 't h app en . If so m e th in g b ad occu rs th ere m u st b e s o m e h u m a n
b e in g o r g ro u p o f h u m a n b ein g s w h o caused it o r w h o sh ou ld have
prevented it from happ enin g. M a n y p eople m a y su e p rim arily to c o n ­
firm this co re b e lie f a b o u t th em selv es and th e world. S o m e re c e n t law
suits confirm this view.

• T h ere was a flood in O ahu, Hawaii d u e to s o m e heavy' torrential

rains. S o m e hou ses w ere destroyed and an eld erly m a n died. His
wife sued th e local c o u n c il for dam ages.
• A b asketb all fan sued th e co a ch o f his local p rofessional team
b e c a u s e th e tea m was h av in g a losing session.
• A w o m a n in Florida sued th e c o m m u n ity b e c a u s e s h e hurt h er
retina look in g at a partial eclipse o f th e sun. Sh e said th e local
papers shou ld h a v e w arn ed her.
• Several parents h a v e sued record c o m p a n ie s b e c a u s e t h e ir ch ild ren
were psychologically d am aged (o n e c o m m itte d suicide) after listen­
ing to rock music.
• Several p e o p le h a v e sued to b a c c o c o m p a n ie s b e c a u s e they sm o k ed
cigarettes for 4 0 years and e n d e d up getting cancer.
Cross-cultural Cognitive Therapy 409

• A n y tim e a n o p e ra tio n d o esn 't w ork o r a m edical treatm en t foils,

physicians are v u ln e ra b le to a m alpractice suit.
• A m a n drinks too m u ch in a b a r a n d gets into an a u to accident, but
su es th e b a r te n d e r for serving him the drinks.
• People in C alifornia sued the local cou ncil b eca u se they were
attacked b y a m o u n ta in lion.
• In C olorad o s o m e skiers skied out o f b ou n d s, th e n sued the ski
resort b e c a u s e o f an avalanche.

T h e A m e rican cultu ral attrib u tio n that s o m e o n e is always to b la m e

is a relatively re c e n t d e v elo p m en t. Prior to th e present century, m an y
A m e rica n s accep ted that b ad th in g s can h a p p en b y accident. It would
b e difficult to im a g in e a p io n e er farm er su ing b e c a u s e his crops failed
o r b e c a u s e his d a u g h te r c o n tra c ted sm all pox and th e co u n try d o c­
to r co u ld n 't help. Even if th e m e ch a n ism s for su in g had b e e n as c o m ­
p re h e n siv e th e n as they are now, th e farm er w ould h av e felt it
im m o ra l to b la m e a n d take m o n e y from o th ers for his ow n misfor­
tunes.
But the world has changed . M a n y A m ericans no longer b eliev e that
a fickle and pow erful n a tu re con stan tly surroun ds them . They
sw itch ed their b e lie f a b o u t th e p ow er o f n a tu re and the pow er o f
hu m anity, and now assu m e that any cata stro p h e or m isfortune occu r­
ring in th eir lives is m a n m a d e rather th a n natural. T h ere are n o longer
acts o f G od; if s o m e th in g b ad happens, so m e person is to blam e.
B e cau se o f this cu ltu rally driven attribu tion, instead o f cursing the
gods, p e o p le n ow curse hum anity, and they have a way o f fighting
b a ck — th ey sue.

Com m ent
A client's cu ltu ral beliefs are rarely challenged directly. Instead the
therapist usually helps the client identify th e cultural source o f the
co g n itio n s and th en allows them to decide how useful th e b e lie f is.
O n e o f th e m ost im p o rta n t cultural beliefs is religion. It essential
th at th e therapist is fam iliar with the religious perspective o f the client
and in corp orates this v ie w p o in t in cou n selin g (see Cox, 1973; Nielsen,
& Ellis, 1994). It is also crucial that clergy and religious w orkers be
fam iliar w ith p sy ch o th era p eu tic procedures. For the b est g u id a n c e in
this area se e p articularly th e w o rk o f Dr. A ndrew W eav er (K oenig &
Weaver, 1997, 1998; Weaver, Koenig, & Roe, 1998; Weaver, Preston, &
Jerom e, 1999).
410 T h e N e w H a n d b o o k oe Co g n it iv e T h e r a p y T e c h n iq u e s

Further Info rm atio n

I originally p u b lish ed th e client attitu d e su rv ey in M e M u llin &
Casey (1975).
A m a jo r reso u rce for all therapists w o rk in g w ith clients from differ­
en t cultu res is the Intercullural Press, P.O. Box 700, Y arm outh, M E 04 09 6.
It provides tex tb o o k s, m anu als, books, and articles th at teach m u lti­
cultural aw areness, cro ss-cu ltu ra l learning, cultural ad ap tab ility and
m ulticulturalism . O f particular interest are th o se g u id e b o o k s that
describe th e cultural p erspectives and attrib u tio n s o f different so c i­
eties. T h ey are w ritten for W esterners b y a u th o rs w h o a re aw are o f th e
attitudes, values and beliefs b e c a u s e th ey are native to, o r h av e lived
in, the culture. For exam ple, Understanding Arabs: A Guide fo r Westerners;
Good N eighbors: Communicating with the M exicans; Considering Filipinos; Spain
is Different; Exploring the Greek M osaic; Border Crossings: American Interactions
with Israelis; A Fair Go fo r All: Australian an d American Interactions; From Da to
Yes: Understanding East Europeans; Encountering the Chinese; From Nyet to Da:
Understanding the Russians. All th ese and m a n y m ore m ay b e pu rch ased
at th e Intercultural Press.

C o u n s e l in g in D if f e r e n t C u l t u r e s

Principles

T extb ook s th at instruct therapists o n how to co u n sel clients often

a p p e a r adm irable. T hey present tech n iq u es in a neat, clean, logical
manner. But clients are m o re c o m p le x th a n o u r th eories a b o u t th em ,
so in actual practice m a n y tech n iq u es that m a y lo o k g o o d in a tex t­
b o o k can fail w h en applied to real people.
M a n y o f th ese slips b e tw e e n th eo ry a n d practice o c c u r w h e n w o rk ­
ing with clients from different cultures. Despite a d m o n itio n s that
co u n selin g tech n iqu es shou ld w o rk a n y w h ere, m a n y th erap ists h av e
discovered that co u n s e lin g tech n iq u es are n ot u niversally effective. To
their surprise th e y h av e found th a t th e y need ed to adap t th e ir tech­
niqu es w h en w o rk ing with p e o p le from different countries, o r even
w h en cou n selin g clients from different parts o f th e U nited States.

M eth o d
1. C ognitive th erapy is b a sed o n h elp in g clients c h a n g e th e ir beliefs,
and beliefs are highly influ enced b y th e clients' culture. To help
Cross-cultural Cognitive Therapy 411

clients, th erap ists need to b e c o m e intim ately fam iliar with the
client's culture.
2. B e c o m e fam iliar with th e art, music, an d literature o f the culture.
3. Be particularly versed in th e cultural stories, fables, and fair)' tales
(see n ex t section).
4. Talk w ith therapists w h o h av e w o rk ed w ith clients in the culture.
5. M a k e ad ap tations to y o u r tech n iq u es necessary to fit the cultural
needs.

E x a m p le
M y first jo b in Australia was as a psychologist in th e m a jo r public
drug and alcohol hospital n ear Sydney. Patients c a m e for treatm en t
from all o v er Australia. T h o se from the o u tb a ck were h o m e sp u n c o u n ­
try-folk, g en u in e, kind, straightforw ard, b u t u n tu tored in recognizing
certain psychological aspects o f them selves. Those w h o c a m e from
A ustralian cities like Sydney, M elb o u rn e, o r Brisban e w ere m ore ver­
bal an d m ore ed u cated ; they intellectualized th e ir problem s m ore and
had m o re difficulty accep ting help.
All o f th e psychologists at th e hospital con d u cted th erapy in groups.
U su ally 12 or m ore patients were crow ded into a sm all ro o m with few
w indow s and p o o r v en tila tio n ; in th e su m m e r it b e c a m e qu ite hot. We
all sat in chairs, in a circle, staring at each o th e r for an h o u r and a half
several tim es a day, 6 days a week.
T h e early sessions w en t s o m e th in g like this:

SYDNEY MAN: I w an t to say som ething.

YANK CO U N SELO R : G o ahead, Colin.
(Some grum bling fr o m men from the outback)
SYDNEY MAN: I d e m a n d th at w e all do o u r part in picking up on
th e ward. M y jo b is to clean up th e loo b efo re grou p therapy, and
e v e ry b o d y else is m ak in g such a m ess; I alm ost don t have time
to get here.
(Loud noisy outburst from som e other people. You could hear, 'There he goes
whining again." Arguments ensued and people were shouting back and
forth.)
YANK COUNSELOR: Colin has his chance to talk, please let him do so.
(Grumbling fro m others asking w hy did they have to listen to me again.)
SYDNEY MAN: T h ey sn o re too m u ch and don 't w ash e n o u g h
and . . .
N ORTH ERN TERRITORY MAN: (interrupting) Blo od y puff. I guess
 T h e N e w H a n d b o o k o f C o g n it iv e T h e r a p y T e c h n iq u e s

w e're su p p o s e to use p e rfu m e a n d w ear b lo o d y pink p an ties too.

SYDNEY MAN: (addressing Yank counselor) Are you g o in g to let th em
say that to me, Yank? I th ou gh t w e're su p p osed to o b se r v e so m e
rules in here.
(Grumbling fro m som e others; som eone says, Pom m y puff; everyone is talking
at once.)
YANK CO U N SELO R : Colin can talk n ow a n d th e o th ers will get
th eir c h a n c e later.
(I spoke in m y quietest, calmest, most unruffled voice. General pandem onium
breaks loose.)
M E L B O U R N E MAN: S o m e o f th ese y a h o o s d o n 't w ash en o u g h .
T h ey have b e e n here for tw o w eeks and I n e v e r seen a n y o f th e m
wash.
OUTBACK MAN: Eh, m ate? Sp en d in g y o u r tim e p e a k in g into
bloke's sh ow ers again, eh?
(General laughter fro m the country men, strenuous objections fro m the city peo­
ple, everybody talking at the top o f their voices.)
BRISBAN E MAN: W h at's th e o u tb a c k w o rd for foreplay? . . . S h ea r­
ing!
(All the city people start laughing hysterically w hile the country men m ake
threatening remarks an d raise their fists.)
S N O W Y MOUNTAIN MAN: Hell, e v e ry b o d y stinks in here.
(The storm erupts again. Yells o f approval fr o m the city folks, an d laughter fro m
the outback men saying, "We will sh ow you w ho stinks an d w ho doesn't.")

S o m e b o d y said, "W h y d o w e h av e to ro o m w ith s h e e p -p o k in g

sw ag m e n anyw ay?" A n o th e r said, "W h y d o I h a v e to b e in this d a m n
hospital in the first place sin c e w h at's w ron g w ith h av in g a c o u p le o f
sch o o n e rs o f b e e r anyway."
The r o o m erupted with catcalls a n d la u g h ter again and a m a n from
Bendigo said h e hadn't stop p ed at o n ly tw o b eers sin ce h e w as 10. I
interrupted in m y calm est m a n n e r saying, "W e sh o u ld n 't all try to talk
at once."
Everybody kept o n sh ou tin g at each o th e r despite m y request, and
I heard so m e o n e in th e back o f the ro o m say u n d er th e din o f noise,
"W h y d o w e have to have a b lo o d y Yank as a drug c o u n s e lo r anyw ay?"
T h en s o m e o n e said th e fo o d stu n k an d this o p e n e d u p further
co m p lain in g with p e o p le sh o u tin g b a ck a n d forth.
That session was su p p osed to b e a lecture a b o u t th e b io c h e m ic a l
c o m p o n e n ts o f addiction. I had b e e n trying to give th is lecture fo r se v ­
eral sessions b u t had n e v e r Joeen a b le to.
Cross-cultural Cognitive Therapy

T h e te m p e st o f so u n d s cycling arou n d th e ro o m sto o d in stark c o n ­

trast to th e drug co u n selin g grou p s I had run in A m erica— th ere the
p rocess had g o n e q u ite well. O n e could b e d em o cra tic a n d let any­
b o d y talk w h o w an ted to. T h ere w asn 't m u c h o f a p ro b lem with noise,
m ost p e o p le w e re polite a n d stayed o n th e topic. T h e therapist's job
w as to facilitate th e g ro u p and gu ide th e p e o p le in a th erap eu tic direc­
tion. O n e could b e n o n d irectiv e w ithou t forcing one's views o n any­
body. Mostly, th e therapist sim p ly reflected th e group's feelings or
qu ietly asked g en tle q u estio n s for th em to th in k ab out. It all had
se em e d to g o a lo n g so sm o o th ly and softly and quietly. But this! W hat
w as this?
G rou p after group, th e sessions w ould b e th e sam e. T he noise in all
th e g ro u p s was constant. C om p laints and epithets were throw n at
e v e r y b o d y a b o u t everything. Despite it all I kept m y cool. I stayed
em p ath etic, facilitative, and c o n tin u e d to em p loy all th e techniqu es
th a t I had b e e n tau g h t a n d had found effective w ith Americans. But
after a w h ile th is co n sta n t din started to bu ild up, and during o n e ses­
sion, I'd had it. It was a hot day a n d a particularly noisy session w h en
I su d d en ly sto o d up and sh ou ted so m eth in g like:

Shut up. Everybody, Sh u t up! It doesn't m atter w h o smells,

w h o snores, or h ow b ad th e food is. All you r w h in in g is ju st so
m u c h koala crap, dingo dung, and platypus piss. You are just
d ru nks and ju nk ies, w h o are h ere b e c a u s e you h av e m essed up
y o u r lives so b ad ly th at so m e b o d y had to throw you into this
hospital. This is n ot th e Sh era to n Hilton hotel. W e are n ot a god ­
d a m n co u n try club. You are n o t here to h a v e a rest or to en jo y
y o u rse lf o r to sm ell sweet. You are here to get sober. You have
o n ly a few w eeks to learn, so y ou don 't have tim e to w aste c o m ­
plain ing a b o u t ev eryth in g u n d er the g o d d a m n sun. I don 't give
a k a n g a ro o 's ass w h e th e r you are from Sydney o r Bou rke or any
o th e r place. There are n o h ig h -class drunks o r ju n k ies in here;
you are all th e sam e. You are ru n n in g out o f g o d d a m n tim e to
sav e y o u r lives, so you b e tte r start listening right now, b efo re I get
m o v ed to th e p oint o f an n oy an ce.

Had this b e e n said du rin g a g ro u p session in the United States, the

patients m ig h t h av e physically attacked, or at the least they m ay have
sto o d u p and w alked o u t saying th ey w o u ld n 't let a n y o n e talk to them
in this way. P ro b a b ly th ey would have walked dow n to th e d ire cto rs
office e n m asse an d co m p lain e d a b o u t h ow u nprofessional I had b e e n
a n d h ow I had cursed at th em . T he director w ould have called m e into
414 T h e N e w H a n d b o o k q e C o g n it iv e T h e r a p y T e c h n iq u e s

his office an d w ould have e ith e r fired me, su sp e n d e d me, o r required

m e to apolog ize to each client in person. A c o m p la in t would p r o b a ­
bly have b e e n filed with th e state drug and a lco h o l licensing board.
B u t here, in this Australian group, an a m az in g .thing h ap p en ed . T hey
all turned arou nd, look ed at me, and got quiet. T h ey didn't cu rse back
or act offended, o r h av e a " n o b o d y - c a n - ta lk t o -m e -lik e -t h a t " ex p re s­
sion o n their faces. T h ey sat expectantly, look ed at m e and w aited for
w hat I was g o in g to say next. I to o k m y o p p o rtu n ity and said s o m e ­
th in g like,

Ah . . . well . . . that's b etter . . . eh. Well now, th e reason you

are . . . e r . . . addicted is that you all h av e this b io ch e m ic a l pre­
disposition that y ou p ro b a b ly in h erited . . . a h e m . . . w h ich
m e an s you r b o d ie s can't h a n d le th ese ch em icals like o th e r p e o ­
ple. Now th e way it w orks is like this . . .

I then w ent to the blackboard and started drawing diagram s o f brains,

endorphins, and neurons. They sat up and listened attentively; som e
even took out little n oteb ook s and copied m y drawings. Amazing!
M y o u tb u rst w orked here b e c a u s e th e cultu re in Australia is c o n ­
siderably different from th at in the United States. W h ile A m erican s
m ay b e m o re physically v iolent and q u ic k e r to tak e physical action
w h en w ronged o r insulted, th ey are less pron e tow ard verbal aggres­
sion. You can h e a r A ustralians say things m ost A m e rica n s w o u ld n 't
th in k o f saying. But w h a t w ould h av e b e e n fightin g w o rd s in th e
U nited States were ju st w ords to Australians. Australians to lera te v er­
bal aggression far m o re th a n Am ericans, b u t th ey are far less toleran t
o f physical abuse. As th ey say there, "W ords? No worries, mate."
E m p athy and positive regard had w o rk ed in th e U nited States, b u t
had laid an egg in Australia. In Australia a therapist is an a u th o rity
figure and so is ex p e cted to act like one. T h e g ro u p m e m b e r s assu m ed
that an au th o rity w o u ld act dom inant, critical, and forceful. A n y th in g
less would b e considered w im py and w o u ld result in a loss o f respect.
Because I was a Yank, the p eople g a v e m e a small break, b u t m y U.S.
co u n selin g style w asn't effective. Not until I sp o k e up, ch allen g ed
them , and co n fro n te d them , did th ey b e c o m e willing to listen to me.
Had I d o n e this in the U nited States I m ig h t h a v e b e e n p u n c h ed o u t
o r sued. But in Australia m y b e h a v io r was co n sid e red a p p ro p riate and
expected. B ecau se o f m y outburst, I h a d ea rn ed th e ir respect and the
right to b e listened to.
T h e p oin t o f this story is also o n e o f th e p o in ts o f this chapter. Pro­
Cross-cultural Cognitive Therapy 415

fessional c o u n selo rs don 't sim p ly apply abstract th eories to disem ­

b o d ie d peoples' p ro b lem s— th ey attem pt to help people, and those
p e o p le are b o r n an d raised in a culture. The cultu re doesn't o n ly pro­
v id e languages, esthetics, or c u sto m s to th e clients; it also gives them
th e m e ta p h o rs th r o u g h w h ich th ey interpret ev eryth in g arou n d them .
To c o u n s e l a n y o n e effectively you h a v e to im m erse you rself in their
cu ltu re so that y ou can see th e world th ro u g h their eyes.

Com m ent
I don 't reco m m e n d m y outburst. I have included it to d em onstrate
th a t the relation sh ip b e tw e e n a client and a m en tal h ealth profes­
sion al is idio m atic to th e specific culture. It is the cultu re that defines
w h at th e social roles o f d o c to r a n d patient sh ou ld be, and different
cultu res h a v e different role expectations. T h e therapist c a n n o t trans­
plant th e c lie n t-c o u n s e lo r relationship h e learned in New York to east
Texas, Hawaii, or Sydney, Australia. If w e are to b e effective therapists,
w e had b e st learn th e relationsh ip idiom allow ed us w ithin th e local
culture.
O n e o f th e m ain idiom s all therapists m u st learn w h en counselin g
in o th e r cultu res is lan gu age and expression o f th e culture. I have
fou n d th at u n d erstan d in g a client's langu age can b e a big problem .
M a n y years ago I saw a client from east Texas. He was a y o u n g
a d o le sc e n t b o y w h o had b e e n b o r n and raised in the local area. His
m in iste r had sent him fo r th erap y b e c a u s e h e was depressed ab o u t
losin g his girlfriend. He lived with his family in the b ack w ood s o f east
Texas and had n ev er b e e n to a town before. T he cou n selin g office was
o n the se co n d flo o r o f a tw o-story, college adm inistration building,
b u t h e refused to g o up stairs. H e said he h ad never b e e n o n a second
flo o r b efore, and didn't understan d w h y ev ery b o d y didn't fall
throu g h. T h e co u n selin g sessions were co n d u cte d on the cam pus
lawn. _
His first w ords were unusual. He said so m eth in g like, "I m b e e n laid
pretty low b e c a u s e o f sufferins. C h a w in -u p ain't m y meat, b u t th e
pard n o tio n s ye to b e a fixen me."
I r e m e m b e r b e in g horrified. All th ese years o f sc h o o lin g to b e c o m e
a psychologist, a n d I h adn't a clu e as to w h at h e h ad ju st said. How
could w e co u n sel togeth er? W ith practice, however, I learned, so I can
now tra n sla te his c o m m e n t: "I have b e e n depressed b ec a u se o l the
pain o f losin g m y girlfriend. I a m not very g o o d at talking a b o u t such
416 T h e N e w H a n d bo o k , o f Co g n it iv e T h e r a p y T e c h n iq u e s

things, b u t m y m in iste r believes you m a y b e a b le to help me."

After havin g m astered th e local idiom, I m o v ed an d w as c o u n s e l­
ing p eople w h o sp o k e in a totally different parlan ce— th e so u th e rn
G e o rg ia -n o rth e rn Florida vernacular. After struggling w ith these
dialects for a while, I fou n d m y se lf c o u n s e lin g clients from W est Vir­
ginia w h o h av e a lilting twang, an d th e n clients from rem o te R ocky
M o u n ta in regions w h o sp o ke in a guttural sh o rth an d . It to o k m e years
to understand all o f th ese idiom s adequately.
At last, after years o f seein g clients from all o v e r the U nited States,
I felt I had learn ed e n o u g h to h av e a rea so n a b le c h a n c e o f u n d e r­
standing m ost A m erican dialects. But w h en I w en t to co u n sel in Aus­
tralia, I was th row n into c o n fu sio n a n d p u zz lem en t again. I had picked
an En g lish -sp eak in g country, th in k in g th a t clients a n d therapists
w ould b en efit from sp ea k in g the s a m e language. But w h a t I found
was th at Australian English is w orlds different from the A m e rican ver­
sion.
T h en I traveled to Hawaii. Hawaii has a m ix o f several interesting
dialects. T h e big island isn't like O ah u , w h e re H on olu lu is. It's m o re
like a third-w orld, Pacific-Basin country. T h e locals are kind, g e n tle
people, b u t th e y sp eak a c o m b in a tio n o f H aw aiian a n d pidgin English
difficult for th e ou tsid er to understand. A client w h o was a c o c a in e
addict sent b y his p rob ation officer said at o u r first session, "How's it
. . . b u m m a h s m an. W e got c o m e h a o le de kine p lace from now ? W h a t
y ou say brah? Fo' real? Eh?"
After a year o f studying several dialects o f pigeon English, I fin ally
could tr a n s la t e ," How are you . . . This is u n fo rtu n a te news. Do I h a v e
to attend co u n selin g sessions at th e office o f a C au casian therap ist reg­
ularly? A m I in terpretin g th e situ ation correctly? Is this true?"
Later I learned to a n sw er in kind, "Yeah____You g o t com e, brah."
I b eliev e that m a n y therapists m ak e m istakes that are not b a sed on
m isdiagnosis o r lack o f skill, b u t are instead based o n failure to kn ow
th e particular idiom s th at th e client is using, o r failure to c o m m u n i­
cate to th e clien t in an idiom that th ey can understand.

Further Inform ation

There are m a n y g o o d works o n the application o f c o g n it iv e -b e h a v -
ior th erapy in different cultures (see Ivey, Ivey, & S im e k -M o r g a n , 1995;
Hays, 1995; Pedersen, 1991; and Wehrly, 1995).
T h e relationship b etw e en therapist and client is h igh ly d eterm in ed
b y cultu re (O kpaku, 1998). For exam ple, u ntil recen tly d o cto rs in Jap an
Cross-cultural Cognitive Therapy 417

did n't tell patients th eir diagnosis, n o r did th e y ask for inform ed c o n ­
se n t for treatm en t. It seem s th e cultu re has had a n u n q u estio n e d trust
in d o cto rs a n d th e re w as n o reason to co n su lt th e patient a b o u t such
m atters (Kimura, 1998; Reich, 1998). In C hina interfering with a suicide
a ttem p t m a y b e considered culturally improper, b ec a u se in so m e
in stan ces suicide is an o b lig a tio n (Qui, 1998). In m a n y cultu res the
therapists c o u ld n ot b eg in treatm en t w ith o u t th e full co n sen t o f the
fam ily o r th e person resp on sib le for y o u r client (Koenig & Gates,
1998).
T he Intercultural Press (RO. Box 700, Y arm outh, M E 040 96 ) is an excel­
lent reso u rce fo r all therapists w o rk in g in different cultures.

C u l t u r a l S t o r ie s a n d Fa b l e s

Principles

O n e o f the b est ways to find th e core th em es o f a culture is to

b e c o m e fam iliar w ith its favorite stories, art, a n d music. T hroughout
recorded history, values, insights, principles, a n d h u m a n pitfalls to
gu ard against h av e b e e n con vey ed to each new g en eratio n through
th e m e d iu m o f fables, fairy tales, nu rsery rhym es, folk music, and
in d ig en o u s art. W e all r e m e m b e r th e stories and songs w e heard w hen
y o u n g ; th e m orals con vey ed b y th em , w h e th e r true or false, profound
o r silly, have found their w'ay into o u r valu e systems. In th ese sam e
stories th e therapist will find a culture's ideals: the cultural hero, the
m a in cu ltu ral adversary, the core valu e the story is h onoring, th e atti­
tud e th e story is co n d em n in g . Notice h ow the fable reinforces the
g o o d v a lu e w h ile p u n ish in g th e w ron g one. (Usually b ad things h a p ­
p en to th e hero and h e r o in e w h en th ey follow noncu ltu ral values,
su ch as cow ardliness, an tisocial actions, o r overly ind ep en d en t th in k­
ing. G o o d things h a p p e n after the h ero o r h ero in e decides to con form
to th e prevailing social values.)
C ognitive restru ctu ring th erap y recognizes th a t th ere is a role (or
th e se stories in h elp in g clients a ssu m e a m ore adaptive perspective on
th eir lives. C ultural stories, fables, fairy tales, analogies, and m etap hors
in art, literature, and m usic are v a lu a b le m ean s o f co m m u n ic a tin g
s o m e o f th e c o m p le x subtleties o f life to certain clients.
In u sin g th e storytelling tech n iqu e, the therapist has the o p tio n o f
e ith e r c o n c o c tin g his ow n stories b y draw ing u p o n his ow n life e x p e ­
riences o r b y m a k in g use o f th e cultural stories throu g h existing
418 T h e N e w H a n d b o o k o f Co g n it iv e T h e r a p y T e c h n iq u e s

media, in clu d in g th e p u b lish ed w orks o f p o p u la r p o ets and m ag azin e

and b o o k writers. T h e stories thus used m a y b e lo n g o r short, fu n n y
o r serious. T h ere are o n ly tw o essential req u irem en ts for th e u se o f
this tech n iq u e: (1) T he story m u st b e relevant to th e circu m stan ces o f
each client, and (2) th e story m u st co n ta in w ithin it at least the essen ce
o f a bridge b e tw e e n th e client's old, d a m a g in g b e lie f and a new, pre­
ferred belief.

M e th o d
1. Synthesize th e client's core beliefs in to a story. Each sto ry sh ou ld
consist o f th e m a jo r situations th e clien t has faced, th e m a jo r e m o ­
tional responses, and, m ost importantly, the principal th e m e s or
attitudes, n o tin g especially th o se th at are false or negative.
2. T he therapist sh ou ld th en m ak e up a story to ex p la in h o w a n d w h y
a n y ev id en t false th em es developed , and how th ey n egatively
ch an ged the client's life.
5. Halfway th ro u g h th e story, th e therapist sh o u ld sw itch the th e m e s
toward a m ore rational, useful perception. Attach this new p e rce p ­
tion to a v a lu e h ig h e r in th e client's hierarchy. Identify th e positive
changes that o c cu r to the m ain ch aracters in th e sto ry b e c a u s e o f
th e new perception.

The story can b e a fable, fair)' tale, o r ex ten d ed m etap hor, d e p e n d ­

ing u p o n w h at g e n r e seem s m ost useful in persu ad ing a particu lar
client. Prepare the story a h ea d o f tim e an d h a v e th e client ta p e it, so
that th e client can refer to it w h e n needed.

Exam ple
W h e n I w orked o n th e Big Island o f Hawaii, I n eed ed to m a k e so m e
radical ch an g es in th e w ay I con d u cted psychotherapy. I had to learn
to adju st to the island culture.
The Big Island is an u n u su al society. It's a g e n tle culture. T h e spirit
o f alo h a p e rm ea tes m u ch o f th e society an d is p articularly ev id en t in
the local H aw aiians b o rn there. Useful in o th e r places, form al classes
with didactic instru ction are to o h arsh and w o u ld v io la te th e spirit o f
the culture. W h a t does w ork is a th in g called talking story, w h ic h is a part
o f their local culture. O n th e Big Island m a n y locals sit a r o u n d an d
co n v ey ideas b y m a k in g up stories. They tell th ese tales in a c o n v e r­
sational, relaxed m anner. T h ey m a k e u p lon g stories th a t h av e full
descriptions o f the local e n v iro n m e n t an d n u m e ro u s details a b o u t th e
Cross-cultural Cognitive Therapy 419

people, b u t h id d en aw ay inside each story is a little principle or a

sm all m axim .
To a h a o le (foreigner from a W estern culture) these stories seem
pointless. T h ey a p p e a r to ra m b le o n w ithou t p u rpose or direction, and
th e m e a n in g o f th e story is hidden aw ay a m o n g layers o f u nnecessary
descriptive detail. W esterners w a n t th e stories to get to th e point.
H aoles w ish th e storyteller w ould go to a b lack b o a rd and diagram the
idea b e h in d th e story.
But to th e native Big Island er talking directly ab o u t ideas out o f
c o n te x t is m issing the point. T hey wisely suggest that all ideas and
a b stractio n s c o m e from people, and that p eople all live in a place, and
th e se p e o p le c o m e from a lon g line o f an cestors w h o have lived in this
place. Therefore, all ideas, concepts, m axim s, and principles c o m e from
people, w h o c o m e from ancestors, w h o c o m e from the land.
To native Haw aiians, draw ing ab straction s o n b la ck b o a rd s would
b e a sacrilege, b e c a u s e the concep ts are dissected from th e total e n v i­
r o n m e n t from w h ich ideas com e. T hey o b je ct to this dissection, m uch
as th e y o b je ct to m ed icating depression separate from the person w ho
is depressed. H aw aiians prefer a m o re holistic approach, and suggest
th a t su ch dissection ignores th e fact that the depressed person is a
p erson w h o lives in a family, and that th e family lives in a society, and
that th e society lives in th e natural en v iron m en t.
In ord er to w ork w ith p eople o n th e islands, I needed to learn to sit
a ro u n d a n d talk sto ry w ith them . So instead o f d iag ram m in g m y ideas
o n a b la c k b o a rd as I have d o n e o n th e m ainland, o n th e Big Island I
in co rp o rated various ideas and principles into fables and tales. W h e n ­
e v e r p ossib le I used H aw aiian legends, w h ich I found have a store­
h o u se o f useful stories.
Here is one. It teach es p eople to challenge their superstitions and
face th eir fears.

The Cove o j Black Pearls

In a n c ie n t times, long b efo re Captain C ook c a m e to the
islands, th e re was a tiny cove n ear H u m u h u m u Point. It is g o n e
now, fo r M a u n a Loa has long since reclaim ed w h at is hers, but
lo n g ago it w as there. It was a sheltered co v e around a p ro m o n ­
tory that kept th e o p e n o c e a n out. A small, g r e e n -b la c k sand
b e a c h w ith a tall c o c o n u t grove b o u n d it on o n e side, and o n the
o th e r side a steep wall o f lava rose for h u n d red s o f feet.
The w a te r inside this co v e was u n u su a l and n o w h e re else was
th e re w a te r like it. It had a dark em erald hue, crystal clear to the
 T h e N e w H a n d b o o k o f C o g n it iv e T h e r a p y T e c h n iq u e s

b ed 30 feet below. At the d eep est part o f th e cove's b ed lived oys­

ters. T h ey w ere not found a n y w h ere else. S o m e o f th e oysters had
pearls o f th e m o st e x q u isite sort. T h ey w ere perfectly rou n d and
had a b lack tu rq u o ise hue. T h ey had a luster so d eep and rich
that th ey created an iridescent b e a m o f tu rq u oise, em erald , and
purple c o m in g from deep w ithin th e pearl. No o n e had e v e r seen
th eir like.
T here w ere k a m a h a m a s w h o lived in a sm all village n e a r the
co v e a b o v e the lava cliffs. T h ey w ould clim b d ow n into th e cove
and dive for th e pearls. Sin ce th e pearls w ere so b eau tifu l and
u nique, th e natives traded th e m to th e o th e r islands an d th e vil­
lage b e c a m e p rosp erou s— all shared in th e w ealth o f th e pearls.
But o n e day the go d d ess Pele got an g ry and se n t lava from
M a u n a Loa to e n g u lf the cove. S h e se n t b ro a d rivers o f fire from
the sou th w est rift zone, dow n the slopes o f th e vo lca n o , o v e r the
ov erh a n g in g cliffs, and cascad in g d o w n into th e cove. T h e sea
c o o led th e flam ing rivers and en ca p su la ted the c o v e in a d o m e
o f petrified lava. A m o u n ta in o f im p e n e tra b le m o lten ro ck hid
the co v e ben eath .
W ith o u t th e pearls the villagers so o n lost th eir w ealth and
b e c a m e p o o r and destitute. But th e y passed th e story o f th e co v e
from father to son for gen eration s. In this w ay th e y kept alive the
m e m o r y o f th e co v e o f b lack pearls.
Several h u n dred years later th e p e o p le still told th e sto ry o f
the pearls, b u t they had long since forgotten th e location o f the
cove.
O n e day a y o u n g b o y was traveling to th e sacred City o f
Refuge up th e coast, b u t h e decided to take a n o t h e r route. He
w alked across a lava d o m e and noticed a crevasse. T he w ind and
sea o f h u n d red s o f years had w o rn aw ay a h o le in the lava. He
was curious, so h e stu ck his torch in to the crevasse a n d lo o k ed
inside. There appeared to b e a large cave u n d e rn e a th w ith o c e a n
w ater flow ing in from the b o tto m . It was a sm all hole, b u t he
m anag ed with difficulty to c lim b inside. At th e b o tto m h e found
th e g r e e n -b la c k sand beach. T he walls o f the ca v e w e re h o n e y ­
co m b e d with eaves w h ere o n e to rren t o f fire after a n o th e r had
rolled dow n in the an cien t times. O n o n e side h e saw the
b u r n e d -d o w n c o c o n u t grove a n d th e holes in th e lava w h ere the
tree trunks had o n c e stood. T h e lava retain ed th e im p rin t o f the
b ark from w h en th e trees had fallen u p o n th e b u r n in g river, and
a perfect im pression o f every b r a n c h and lea f was sta m p e d in the
Cross-cultural Cognitive Therapy 42.1

frozen lava. But w h at caused him to gaze in a m a z e m en t and

w o n d e r w ere th e flashes o f lights o n th e ceiling. Reflected o ff the
walls o f th e cave were b rillian t flashes o f turquoise, glistening
dots o f pu rple interm ing led with em erald.
He low ered his torch to th e g r e e n -b la c k sand b e n e a th his feet
a n d saw w h at was cau sin g th e reflection. Stretching out before
h im in th e san d w ere h u n d red s o f b lack pearls casting iridescent
b e a m s o f turquoise, em erald, and pu rple o ff th e walls o f th e cave.
Im m ed ia tely h e k n e w w h ere h e was. He knew that after all these
c en tu ries h e had discovered th e lost cove o f b lack pearls. He
ex cited ly g r a b b e d all the pearls h e could, hid them in his clothes
and rushed to th e City o f Refuge. He ran b y the city's huge,
tw e n ty -fo o t-w id e , sto n e walls into the o b lo n g sq u are o f the
th re e a n c ie n t tem ples. T h ere h e entered th e sacred san ctu ary o f
th e priests o f Lono and spread o u t the pearls for th e priests to
see.
Initially th e priests w ere ecstatic. Finding th e pearls would
b rin g prosperity b a ck to th e island and they w ould b e rich. But
th en th e y started to w'orry. If th e p e o p le heard th at th e black
pearls had b e e n found, they would all rush to th e cove, take the
pearls, and leave little for th e priests. T h ey could n't keep th e dis­
cover)' secret since they w ould b e trading th e pearls to th e other
islands. W h a t could th ey do?
T h ey th o u g h t a b o u t it for m a n y days until finally the high
priest fou n d a solu tion that all o f th e priests agreed was a per­
fect plan. T hey w ould m a k e th e cave taboo.
T he priests told the b o y th a t th e cave was n ow tabo o. They
said th a t h e had desecrated th e cove o f b la ck pearls and that Pele
had se n t evil m e n e h u n e s to guard th e cove. T hey explained if
a n y o n e n o w entered the cave, th e m e n e h u n e s w ould possess the
person 's b o d y and ca u se it to explode. T h ey told him that only
th e priests o f Lon o were sanctified en o u g h to resist th e taboo,
and o n ly th ey could e n te r th e cove.
T he b o y stayed aw ay from the cave alon g with all the o th er
villagers. T h e priests got richer and the p eople got poorer.
A fter a y e a r or more, the b o y started to get curious. He didn't
ca re a b o u t th e pearls, b u t b e in g a b o y h e b e c a m e m ore and m ore
interested in th e m e n eh u n es. He had n ev er seen o n e b efo re and
w o n d ere d a b o u t w hat th ey look ed like and h ow th ey could
m a k e things explod e. So o n e d ay h e decided to ask th e priests.
He w e n t b a ck to the City o f Refuge and asked th e high priest o f
 T h e N e w H a n d b o o k o f Co g n it iv e T h e r a p y T e c h n iq u e s

L ono w h a t m e n e h u n e s look ed like. Tl\e priest told h im that

m e n e h u n e s w ere invisible and that n o b o d y c o u ld see them .
"Then h ow d o you know they are there?" asked the boy. The
high priest got angry and told the b o y to g o away. T h ey said if he
ever entered the cave again th e m en eh u n es would get inside him
and m a k e him explode, and that then h e would know well enough
that there were m en eh u n es and w hat they could d o to him.
But th e b o y w asn't satisfied. He kept th in k in g a b o u t th e
m e n eh u n es, and exploding, an d th e co v e o f b la ck pearls. O n e
m o o n lit night his curiosity got th e b est o f him . He g r a b b e d a
wild piglet he had snared a n d crept to th e cave. G radu ally he
low ered th e pig dow n o n to th e b e a c h and w aited for it to
explod e, b u t it didn't. It kept sq u e a lin g and ru n n in g b a c k a n d
forth across the g r e e n -b la c k sand. He w aited and waited, b u t still
the pig didn't explode. Finally h e decided to take a c h a n c e and
clim b dow n himself. Terrified, h e c lim b ed into th e cav e a n d
look ed around. He kept w aiting to explod e, yet h e n ev er did.
After a w hile h e g r a b b e d so m e b lack pearls an d th e pig an d ran
h om e. He show ed the pearls to th e villagers, told th em a b o u t the
c o v e and told th em w h a t th e priests o f Lono had done.
T he p e o p le realized th ere was n o ta b o o a n d that th eir priests
w ere lying to them . T h ey discovered th a t th e priests’ teachings
w ere o n ly superstitions aim ed at keeping th e p e o p le poor. The
priests had held the fattest offices in th e land, h a d b e e n rich and
powerful, had sto o d even a b o v e th e chiefs, b u t n ow th ey w ere
show n to b e frauds, im postors, and fakes.
So, th e p e o p le gath ered an d rose up in a m ig h ty m ass against
th e priests o f Lono. After a great battle, all the priests w ere slain
and th eir influ ence was rem ov ed from th e islands.

T he story was helpful to m a n y clients. A n x iou s clients from the Big

Island u n d ersto o d th e m oral: Challenge your superstitions. W h e n this
principle w as exp lain ed using o th e r m eth o d s, th ey h a d n 't u n d e r­
sto o d — the m a n n e r o f e x p la in in g was to o foreign to th e m — b u t w h en
I con vey ed th e m essage throu g h this story, th ey u n d e rs to o d a n d b e n ­
efited from th e lesson.

Com m ent
Ideally, an approp riate story' o r fairy tale sh ou ld c o m e rolling "trip­
pingly o ff th e to n g u e" o f th e therapist at exactly th e right m o m e n t
Cross-cultural Cognitive Therapy 423

du ring a session. However, therapists w h o lack that particular kind o f

creativity c a n still m a k e effective use o f this techniqu e. T h ose w h o
c a n n o t d ev ise a n ap p rop riate story' will sim ply h a v e to devote m ore
tim e and en e rg y to p la n n in g in a d v an ce how best to interw eave sto­
ries from s o m e o th e r so u rc e into th eir overall strategy for effecting a
p e rce p tu a l shift in a particular client.
Nothing, however, will replace th e hard w ork the therapists need to
put in to b e c o m e intim ately fam iliar with the cultu res o f their clients.

Further Inform ation

S in ce p sy ch otherapy began, c o u n selo rs have b e e n u sing stories to
c o n v e y psychological co n ce p ts in ways that clients could understand,
b u t little research has b e e n u n d ertaken to d eterm in e the effectiveness
o f su ch interw eaving. S o m e ex cep tio n s h av e b e e n : Lazarus (1971, 1989,
1995), and particularly th e imager)' and fantasy w ork o f Singer (1974,
1976, 1995), Singer and Pope (1978), Sheikh and Shaffer (1979), and
S h eik h (1983a, 1985b). D onnelly an d D u m a s (1997), M artin, Cummings,
a n d H allberg (1992), M cC urry and Hayes (1992), and Siegelm an (1990)
h a v e exp lored th e im p o rta n ce o f analogies and m etap h ors in thera­
p eutic situations.
M ilton Erickson is o n e o f th e b e s t-k n o w n th erap eu tic storytellers.
S ee B an d ler a n d G rin der (1996), Erickson (1982), Havens (1985), and
L an k ton and Lankton (1983) for so m e exam ples.
For o th e r th era p e u tic use o f fantasy see Duhl (1983), G ordon (1978),
L eu n er (1969), S h o rr (1972, 1974), a n d sy m b o lic m od eling o f Bandura
and B arab (1973).
T he fantasy literature o f different societies often reveals the core
attitudes a n d values o f cultures. There are so m e g o o d fantasy a n th o lo ­
gies from different countries: New G u inea (Gillison, 1995), Scottish,
(M anlove, 1997), Celtic (Yeats, 1990), D utch (Huijing, 1994), Portuguese
(De Q uieroz, 1995), Polish (Powaga, 1997), British (Stableford, 1995),
Jew ish (N eugroschel, 1997), H u n garian (Ivaldi Cdtud, 1995).
T he therapist will also find a culture's m y th olo g y a useful store­
h o u se o f cultural cognitions. For a general review o f folklore and
fables see Sm ith (1995). For the stories and fables o f the So u th Pacific
see th e M a m , a m u ltiv o lu m e jo u r n a l o f langu age and literature o f
Oceania (M a m , 1980). Norse m y th olo g y can b e fou n d in th e Prose Edda
from Icela n d ic tra n sla tio n s (Young, 1954). Australian m y th s are
recorded in A boriginal M yths: Tales o f the Dreamtime b y Reed (1978).
H aw aiian m yths, oral traditions, an d historical tales are reported by
424 T hf . N e w H a n d b o o k o f Co g n it iv e T h e r a p y T e c h n iq u e s

F o rn an d er (1996). Fables a b o u t th e origin o f th e u n iv erse a n d th e ori­

gins o f m a n can b e found in Philip Freund (1965), M yths o f Creation.
Bulfinch's classic w ork on m o r e fam o u s m y th o lo g ies is a great sou rce
o f cultural th em es (see Bulfinch's M ythology: "Age o f Fable," "The Age of
Chivalry," "Legends o f Charlem agne"). In addition, rev iew King Arthur
and His Knights; H ie M abinogeon, Beowulf, Religion and Folklore o f Northern
India (Crooke, 1926), and that o f Scotlan d (Dalyell, 1935).
 Philosophical Underpinnings

TA His last ch a p ter STATES EXPLICITLY w h a t h a s o n l y b e e n im p lic it in t h e

rest o f th e b o o k — th e p h ilo s o p h ic a l fo u n d a tio n s u n d e rly in g th e p rac­
t ic e o f c o g n i t i v e r e s t r u c t u r i n g th e ra p y .
In th e tw o sections th at follow I offer a b r ie f and som etim es per­
son al discu ssion o f tw o p h ilosop h ical principles. T he first, "W h at is
Rational to Clients?" uses th e law o f p a rsim o n y to help clients to dis­
co v e r w h ich o f th eir beliefs are preferable o v e r o th e r beliefs. The sec­
ond, "W h at is Real to Clients?" discusses using pragm atism to help
clients to sort th rou g h th eir different views o f reality.

W h a t Is R a t io n a l to C l ie n t s ?

Principles

Ever sin ce cogn itiv e th erapy b eg a n m a n y years ago, cognitive ther­

apists h av e b e e n accu sed o f in d o ctrin atin g clients with th eir ow n view
o f w h a t is rational. T h e legitim ate q u estio n s b ein g asked include: W hy
sh o u ld th e clien t accept the p h ilosop h y o f the therapist? W h a t m akes
th e therapist's view o f w h a t is true o r false any m ore valid th an the
client's? Is the claim o f the rightness o f the therapist's view based on
a c a d em ic authority, professional consensus, intuition, d iv ine revela­
tion, scientific im perialism , rationalism , or so m e o th e r philosophical
fo u n d a tio n ?
C ognitive restru ctu rin g th erap y has an answ er to these questions.
T h e therapist's ju d g m en t o f the truth or falseness o f a client's b e lie f is
b ased on the law o f parsimony.
 T u t N e w H a n d b o o k o f Co g n it iv e T h e r a p y T ec h n iq u e s

I explain to m y clients that the law o f p a rsim o n y is o n e o f th e m ost

useful tools availab le to h elp th e m d e te rm in e th e validity o f their
beliefs. At its m ost basic, th e law m e a n s that, all th in g s b e in g equal,
th e sim plest ex p la n a tio n is th e best. A sm all b o o k o n p h ilo so p h y The
Web o f Belief b y Q u in e a n d U llian (1978)— ex p lain s th e princip le well. It
describes th e law o f p a rsim o n y in great detail and gives m a n y c o m ­
m o n everyd ay exam p les that d e m o n stra te its power. I give m y clients
o n e e x a m p le from the b o o k .

Im ag in e that o n e a ftern o o n you get into y o u r tan '99 Su baru

w ag on a n d drive to th e superm arket. You park n ex t to th e s h o p ­
ping cart stall an d g o into the store. An h o u r later y ou return
pu sh ing a cart full o f groceries. You lo o k w h ere you parked y o u r
c a r an d se e a tan '99 S u b a ru w agon. W h a t do you co n clu d e?

T h e answ er is so o b v io u s that m o st clients don 't see th e p oint o f the

question. T hey co n clu d e that it is Iheir car, th e s a m e c a r th a t th ey left
in th at very parking spot. Clients ask, "W hat else could it be?" I a n sw er
that it really could b e a great n u m b e r o f o th e r things. S o m e o n e m ig h t
have stolen their c a r and th e n parked a n o th e r tan '99 Su b aru w ag on
in its place. T he client could b e im ag in in g th e car, or it co u ld b e a
holog rap h o f th eir car, o r it could b e a V W b u g disguised to lo o k like
their car. After a few o f th e se exam ples, th e clients see the p oin t; it is
on ly their im a g in a tio n th a t limits w h at it could be.
The difficulty is in d eterm in in g w hat logic clients and th e rest o f us
use to reflexively assert that it is o u r c a r an d n o t o n e o f th e altern a­
tives. A uthority? There is n o a u th o rity telling us it's o u r car. C o n se n ­
sus? T he p eople in th e parkin g lot did not vote to d e te rm in e w h e th e r
it is o u r car. Divine revelation? M o st p eople w ould d o u b t th a t G od
w o u ld b e co n ce rn ed a b o u t w h ere w e p ark ed o u r car. Scien tific em p iri­
cism? No con tro lled e x p e rim e n t was co n d u cte d to scientifically prove
that it is o u r car sitting there.
W ith all o f those alternatives available, w e sim p ly au to m a tica lly
assum ed that it was o u r car. W h a t m akes us so certain o f th e co rrect­
ness o f o u r an sw er th a t w e d o n 't ev en con sid er th e o th e r possibilities?
Clients u su ally tell us that th ey use th eir logic, th eir reason ing.
T h ey a ssu m e th a t it's th e ir c a r b e c a u s e it is th e m ost p r o b a b le e x p la ­
nation. T h ey h a v e g o n e to th e store 99 tim es b e fo re a n d h a v e alw ays
found th eir c a r w h ere th ey left it, so th ey a s s u m e t h a t this tim e will
b e the s a m e as th e p rev iou s 99; this a n sw e r h a s th e h ig h e st p r o b a ­
bility. M ost clien ts a d m it th a t the o th e r e x p la n a tio n s a re possible, but
th e p ro b ab ilities a re so u n lik ely th at th ey d o n 't n ee d to c o n sid e r
Philosophical Underpinings 427

them . Logic dictates that th ey pick th e m ost p ro b a b le answer.

This ex p la n a tio n m a y b e m istaken. M a n y philosophers, starting
with H u m e a n d en d in g in the p resent day with Popper, assert o th er­
wise. T h ey suggest that ju st b e c a u s e s o m e th in g h a s h ap p en ed a mil­
lion tim es b e fo re th ere is no g u ara n tee and n o probability that the
n ex t tim e th e s a m e th in g will h a p p en again, that just b ec a u se th e sun
has risen every o th e r day is n o g u a ra n tee that it will rise tomorrow.
T h ey p oint o u t that th ere is no logical co n n ec tio n b e tw e e n tom orrow 's
su n rise and all th e p reviou s sunrises; each are in d e p en d en t events.
T h in kin g that ind ep en d en t events are co n n ected in so m e mystical
way is referred to as th e gam bler's fallacy, and m a n y clients m ak e it; it
is th e b e lie f th a t o n e c h a n ce ev en t influ ences the next c h a n ce event.
For instance, w e kn ow that the probability o f getting heads w h en we
flip a coin is fifty percent. W e also know that the probability o f getting
a h ead th e n ex t tim e w e flip th e coin is the sa m e fifty percent. It does­
n't m atter h ow m a n y heads w e get in a row, a h u ndred or a thousand,
th e prob ab ility for th e co in landin g o n heads rem ains fifty percent
each tim e w e flip the coin. But m a n y clients th in k th at probabilities
build up, and that th e coin alm ost know s that after a h u ndred results
o f heads it is su pposed to land as a tail pretty so o n ; th e im petus for a
tail gets stronger an d stronger. But this is absurd. Coins aren't goo d at
rem em b erin g .
A client's car is n o sm arter than a coin. It doesn't r e m e m b e r that it
was in th e parking lot 9 9 lim es before. It doesn't kn ow w h e th e r it is a
h o lo g rap h o r a negative hallu cin ation o r if it has b e e n replaced b y an
identical car.
M a n y m o d e rn p h ilosop hers are c o n v in ced that w e can't prove c o n ­
cepts like cau se and effect, p ro b a b ility or chance. If th ey are right, it is
difficult to d e te rm in e w h y h u m a n s a u to m a tica lly assu m e that th e car
th ey find in their parking spot is th eir car. T hey have n o g o o d reason
for assu m in g it's th eir car despite the fact that th ey m a k e this assu m p­
tion all th e tim e and w ithou t question.
This en tire discu ssion strikes m a n y clients as absurd. T h ey suggest
th at n o b o d y would th in k o f these o th e r options, and that ev eryb od y
w o u ld c o n clu d e that th e car they see is th eir car. T hey claim it is ob v i­
ous, a n d it is, but the reason it's ob v iou s is explained b y the law o f
parsim ony. This law, th o u g h usu ally u n n a m e d and unidentified, is so
ingrained in all o f us that in situ atio n s like o u r ex am p le clients pick
th e simplest, clearest, least c o m p le x ex p la n a tio n w ithout a second
thou ght. T h ey im m ed ia tely assu m e that it's their car and don 't c o n ­
sid er th e alternatives. T h ey use th e law o f parsim on y a thou sand times
428 T i n N e w H a n d b o o k o r Co g n it iv e T h e r a p y T e c h n iq u e s

ever)' day, and th ey d o it so au to m a tica lly th a t th e y aren t ev en aw are

o f it.
But it is this s a m e law o f p a rsim o n y th at clients o ften su sp en d w h en
ju d g in g th eir ow n d am agin g beliefs a n d attitudes. O n e of o u r biggest
jo b s as cogn itiv e therapists is to help clients reap ply th e law that they
use so co n sta n tly for ex terio r ev en ts to them selves.

M ethod
1. W h e n clients are lo o k in g for an ex p la n a tio n for th eir b ehavior, help
them find the simplest ex p la n a tio n first.
The "sim plest" m e a n s the m o st fam iliar o r m o st o rd in ary e x p la ­
nation. For exam ple, if a client squ eezes his to o th p a ste a n d n o th in g
c o m es out h e could co n clu d e th a t th e laws o f physics h a v e b e e n
m ysteriously su sp en d ed for his tu b e o f tooth p aste, that for this
m o m e n t in tim e a n d space the se co n d law o f th e r m o d y n a m ic s— for
every actio n th ere is a rea ction — d o esn 't hold. As w e h a v e seen, th e
fact th at the to o th p a ste has alw ays c o m e o u t b e fo re is n o g u a r a n ­
tee that it will c o m e o u t this time. T h e law o f p a rsim o n y causes us
to reject this n o tio n o u t o f h an d — w e don 't ev en c o n sid e r it. Instead
we co n clu d e that so m eth in g is stop p ing u p th e e n d o f th e t u b e or
th a t th e tu b e is o u t o f toothpaste.
2. Help y o u r clients find th e easiest conclusion.
The law o f p arsim o n y also tells us to search fo r th e a n sw e r th at
requires th e least energy. T he c a r an alog y is a g o o d ex a m p le . T he
interpretation o f w hat w e see in th e parking lot that requ ires the
least a m o u n t o f en erg y is th at it is o u r car. It w ould ta k e a great deal
o f en erg y to rem o v e o u r car and su b stitu te a h o lo g rap h , o r to steal
it and replace it with a n o th e r o n e o f exactly th e s a m e year, m od el,
and color. O u r b rain picks th e ex p la n a tio n th a t requ ires th e least
a m o u n t o f effort.
3. Help y o u r clients pick th e least c o m p le x answer.
T h e in terpretation that is least c o m p lica ted is p referab le to e n t a n ­
gled exp lanations. For exam p le, a Freudian th eorist m ig h t suggest
that w o m en are afraid o f sn ak es b e c a u s e sn ak es rep resen t th e m ale
organ, and th at th o se w o m e n w h o h a v e repressed th eir sexu al feel­
ings will develop a p h o b ia a b o u t a n y th in g that sy m b o lica lly c a n b e
associated w ith the penis. This is a very c o m p le x ex p la n a tio n . It is
m u c h less c o m p le x to th in k that w o m e n (and p e o p le in general) are
afraid o f snakes b e c a u s e b e in g b itte n b y a p o iso n o u s sn a k e c a n kill
us. To the rejoinder, "W h y th e n are p e o p le afraid o f n o n p o is o n o u s
Philosophical Underpinings

snakes?" th e an sw er is that it is often difficult to tell the difference

b e tw e e n th e o n e a n d th e other.

Example: The Story o f Bob

If a clien t totally rejects all th e c o m p o n e n ts o f parsim ony h e o r she
can h av e serious m e n ta l health p rob lem s; o n e o f the m ore severe o f
th ese is paranoia. A clien t n a m ed Bob c a m e to see m e with a n e x te n ­
sive p aran oid delusion. H e believed that u nits o f th e Irish Republican
A rm y w e re out to m a k e h im go crazy and then kill him. This was a
p ecu liar d e lu sio n b ec a u se Bob w asn't Irish, had no co n n ec tio n with
Ireland o r th e Irish, and w asn 't a su p p orter o f an ti-IR A groups, but
s o m e h o w h e had g otten it into his h ead th a t th e IRA had targeted him
as an enem y. There was a b so lu tely no ev id en ce w h a tso ev e r that any­
b o d y disliked him — m u c h less hated h im e n o u g h to kill him.
Like m o st sim p le paranoid patients, Bob was not a generally insane
m an. He was qu ite bright, had a g oo d , h ig h -p a y in g jo b , a wife and
family. He didn't h av e a history o f p an ic reactions or anxiety' and he
w asn't o n drugs. He had a n o r m a l history in ever)' w'ay. T he o n ly event
preced in g his paranoia was a p ro b lem w ith his wife that had pro­
d u ced a m o d e ra te depression. Im m ed iately after his depression had
b e g u n he'd develo p ed his paranoia.
W h e n I interview ed Bob he seem ed perfectly norm al. He was logi­
cal and rational th ro u g h o u t m ost o f th e interview, b u t n e a r th e end
h e asked m e w h e th e r I was Irish. T h e referral agen cy had not inform ed
m e o f th e particular nature o f his delusion, so I cheerfully answered,
"W h y yes. M y g ra n d fa th er Edward Ryan c a m e o v e r from Ireland in the
1890s." At that point, Bob sto o d up with a crazed lo o k in his eye. He
gag ged an d b olted o u t o f th e ro o m with a lo o k o f h o rro r ab o u t him.
I thought, "O h well . . . a n o th e r satisfied customer."
I later fou nd o u t w h a t had h ap p en ed and realized that I couldn't
w ork w ith Bob again, so I co n d u cte d th e th erap y throu g h o n e o f my
Jew ish su p erv isees w h o had n o c o n n e c tio n to Ireland. T h e therapy
was interesting. B o b c o u ld not b e persuaded from his delusion and
w as totally u n a b le to use ev en th e slightest aspect o f the law o f par­
sim ony. Instead, h e would interpret all events in term s o f his delusion.
I f a red -h aired m a n w alked past him o n th e street carry ing a package,
B o b was su re that h e w as from th e IRA and that the package was a
b o m b . He refused to sh o p in a n y store th at had "M ac" o r "Me" or "O"
in its nam e. If h e saw a gre en c a r h e would b reak into a cold sweat,
certain th a t it was an IRA patrol. W h e n th e netw orks broadcast a
430 T h r N e w H a m d bq q jl q f ror.NiTivF Thfrapy Techniques

Notre D am e football g a m e h e w as sure that th e IRA was sen d in g him

cod ed m essages th ro u g h th e a n n o u n c e r s telling h im that his tim e was
up.
W h e n th e therapist argu ed against B ob 's n o n p a r s im o n io u s inter­
pretations, B ob w ould c o u n te r with, "You are n o t aw are o f th e inter­
n a tio n a l Irish co n sp ira c y . I f y o u w ere, y ou w o u ld s e e th e
rea son a b len ess o f m y view." He could not p erceiv e ev en th e easiest
c o m p o n e n ts o f parsim ony, and th erefo re could n ot b e p ersu a d ed from
his views.
T he difficulty in w o rk in g with B ob an d p e o p le like h im is th a t th e
law o f p a rsim o n y is based o n a feeling, not o n logic o r reason in g, and
this feeling is g ro u n d e d on th e c o n ce p t o f b a sic trust. At tim es w e all
need to trust o u r sp o n ta n e o u s, p arsim on iou s, p ercep tio n s o f events.
O n c e this trust is rem ov ed b e c a u s e o f e m o tio n a l tra u m a or s o m e kind
o f brain injur)', th e perception o f p a rsim o n y disap p ears an d it's v ery
difficult to get it back.
I w ish that I could report that Bob w as cured b y s o m e dram atic, p ro­
found technique, b u t h e wasn't. He left the c e n te r after h aving sw itched
from an IRA conspiracy to a Jewish conspiracy, and sin ce th e o th er
therapist was Jewish, w e l l . . . you kn ow w h at happ ened . M a y b e w e had
misread h im and h e was really paranoid a b o u t psychologists— w e
aren't sure.
A colleag u e o f m in e has successfully u sed a p arad oxical a p p ro a ch
to co u n sel s o m e clients like Bob w h o h av e lost th eir ability to apply
th e law o f parsim ony. In his ap p roach th e therap ist b e c o m e s m ore
u n p a rsim o n io u s th a n his clients— h e o u t-p a r a n o id th e paranoia. In
discussing Bob's case, h e told m e th a t h e m ig h t h a v e h a n d led Bob b y
telling him so m eth in g like this.

T h e IRA is ju st a front grou p for th e Jew ish c o n sp ira q '. And

b e h in d th e m is the b lack conspiracy, w h ich jo in ed w ith th e Chi­
nese c o m m u n ists after they c o m b in e d w ith th e M afia a n d Lati­
nos. T he cover organ ization for th e m o v e m e n t is th e N ational
O rganization for W o m e n in c o n ju n c tio n with th e D au ghters o f
the A m erican Revolution. T hey are all fin a n c ed b y th e Save the
W h a les fou nd ation . O f co u rse th e w h o le th in g is run b y th o s e 10
W ASP b an kers in New York w h o e v e ry b o d y kn ow s run e v ery ­
thing anyway.
If y ou really w an t to protect y o u rse lf you m u st gu ard against
all these groups. Now' that I th in k a b o u t it, th at w o n 't w o rk either
Philosophical .Underpinings

b e c a u s e th e y all kn ow that you'll b e o n the lookout for them , so

th ey will c o m e in the disguises that you would least expect. Be
p articularly careful a b o u t old ladies b ec a u se that would b e a
great disguise. Also b e aw are o f p e o p le from Kansas, Iowa, o r any
o f th e m id w estern states b ec a u se you w o u ld n 't n o rm ally suspect
them , w h ich m a k es th em highly suspect. O f cou rse the Irish and
th e Jews are from the east, so keep an eye o n Easterners. And in
the west th ey h av e the Latinos so give W esterners a wide birth.
All foreigners are suspicious b ec a u se you don 't really know
w h e re th ey are from.
Ah, Bob w h at the hell. T h ere are so m a n y p eople from so
m a n y places w h o could d o you in that y o u can't protect y o u rse lf
n o m a tter w hat you do. Looks like th ey are g o in g to get you for
sure. W h y try to protect you rself an y m o re? You m ight as well
h av e the b est life th a t y ou can until th e in ev itable happens,
right? So let's see if I can help you b e as happ y as you can until
th e end com es. Since you 're goin g to die anyway, w h y not en jo y
y o u r life until then. . . .
Now let's see now, W h a t can w e d o to m a k e you r present life
happier? . . .
H u m m . . . W e will h av e to w ork on that. OK, Bob?
By the way, how 's you r wife?"

C om m en t
T he rule o f p a rsim o n y does n o t m ean that all unfamiliar, h igh -
energy, c o m p le x ex p la n a tio n s are w rong; th e rule on ly m e a n s that
clients shou ld pick th e sim plest ex p la n a tio n first, and c h o o se complex,
u n u su a l answ ers o n ly if the sim plest o n e doesn't fit the facts.

F u rther In fo r m a tio n
M a n y p hilosop hers h av e discussed the law o f parsimony. Possibly
the b e st presen tation is by Q u in e a n d Ullian (1978). Also see Q u in e
(1987). Historically, the law is know n as "O ccam 's razor," co m in g from
W illiam o f O ccam , o r O ckh am , a 1 4 th -c e n tu ry English Franciscan the­
o log ian w h o said exactly, "It is vain to d o w ith m o re w hat can b e d on e
w ith fewer" (qu oted b y Bertrand Russell, 1945).
 T u t N e w H a n d b o o k o f Co g n it iv e T h e r a p y T e c h n iq u e s

W iia t I s R e a l to C l ie n t s ?

Principles

T he p h ilosophical origins o f cogn itiv e restru ctu ring th era p y are

sim ilar to the origins o f p sych ology a n d p sych iatry in gen eral. T h ere
has b e e n a d ic h o to m y b e tw e e n w h at could b e called th e m aterial and
th e m entalistic traditions. O n the m aterial sid e th e re is th e v iew th a t
the h u m a n body, the h u m a n brain, an d th e h u m a n n e rv o u s system s
are physical o b je cts in sp a ce th at are su b ject to th e s a m e m ech an ica l
laws th at co n tro l o th e r m aterial bodies. T h ey have size a n d m ass and
w eight; th ey can b e perceived directly b y ou tsid e ob serv ers; th e y can
b e m easured; an d m ost im p o rta n tly th ey o p e ra te d eterm in istica lly in
a c a u s e -a n d -e ffe c t sequ en ce. Radical b eh av io rism , m edical p sy ch ol­
ogy, and n eu ro p sy ch o lo g y h av e all h a rk e n e d b a c k to th e p h ilo s o p h i­
cal m aterialism o f T h o m as H o b b es and the realism o f Jo h n Locke.
Behaviorist therapists su ch as Cautela t o o k b e h a v io ra l m e th o d s
such as extinction, reinforcem ent, an d c o n d itio n in g and placed th em
in th e m in d o f th e su b ject b y adding th e prefix "covert." Thus, early in
cognitive th erapy w e applied tech n iq u es su ch as covert con d ition in g ,
covert desensitization, a n d covert avoid ance. D espite b e in g covert,
these tech n iq u es still o p erated in th e m aterial w orld w ith m e ch a n ic a l
laws, an d w ere su b ject to d eterm in ism and c a u s e -a n d -e ffe c t relation­
ships.
The secon d tradition, m en ta lism , has had an eq u a lly lo n g and c o l­
orful history. Using th e w o rd "m ind" ra th e r th a n "brain" and e m p h a ­
sizing con cep ts su ch as volition, choice, responsibility, purpose,
knowing, and believing, ad h eren ts to this tradition d e scrib e p h e n o m ­
en a th a t are not in space, n ot su b ject to m e ch a n ic a l laws, a n d not
view able b y external ob serv atio n. C o m in g from th e m e n talistic p h i­
losop h y an d idealism o f Plato, G eo rg e Berkeley, a n d E m an u a l Kant,
a n o th e r grou p o f early cogn itiv e therapists c a m e from th e h u m an istic,
Rogerian, o r existential schools. To th e se therapists freed o m o f choice,
rational decision m aking, an d b e in g resp o n sib le for o n e 's ow n b e h a v ­
ior w ere key principles in psychotherapy.
C ognitive therapy, like p sych ology in general, has b e e n tra p p ed in
th e m aterial/m entalistic d u alism th ro u g h o u t its history. T h e p ro b lem
o f recon cilin g the tw o traditions has alw ays b e e n th e sam e, an d th e
c ru x o f the p rob lem can b e stated th ro u g h q u e stio n s su ch as, "How
can m in d s in flu en ce b od ies?" "How c a n m e n ta l c o n ce p ts like ch o ice
and p u rp o se b e described in ph ysical term s su ch as n eu rosy n ap ses,
Philosophical Underminings. 433

c h em ica l transm itters, o r e n d o c rin e secretions? How ca n o n e explain

physical concep ts, su ch as cau se and effect, in term s o f m en tal c o n ­
cepts, su ch as choice, decision, and purpose?
This discu ssion is n ot sim ply a p h ilosophical abstraction, b u t actu­
ally c o m e s into play w h en th e th erap ist has to testify in a c o u rtro o m
as to w h e th e r clients in ten d ed to c o m m it crimes, knew w h at they were
doing, w e re c o m p e te n t to stand trial, o r were in co m p e te n t b eca u se o f
psychosis, insanity, e m o tio n a l traum a, o r drug addiction.
T h e key p ro b le m in ex p la in in g the interaction b etw een the m ental
and the physical world has b e e n m ost succinctly stated b y the m o d ­
ern philosopher, G ilbert Ryle. Ryle described th e p rob lem with his
fam o u s phrase, th e d o g m a o f the G host in the M a ch in e (Ryle, 1949, p.
15-16). T h e ghost in Ryle's m ach in e, like volition inside a h u m a n
being, is a n im m aterial object. It has no size, weight, o r dim ension. It
ca n g o th ro u g h walls a n d doo rs and c a n float a b o v e the ground
b e c a u s e it is n ot su b je c t to physical laws such as gravity. But the
m achin e, like th e h u m a n body, is entirely physical, and su b ject to all
th e laws a n d forces that all m aterial o b je cts are su b ject to. How can a
g h o st affect a m a ch in e? How can o u r will affect o u r actions? If the
g h o st tries to th row a lever o r press a b u tto n on the m achine, its
g h o stly h an d goes right th ro u g h it, tou ch in g no lever and pressing no
b u tton .
In cogn itiv e th erap y w e tak e this c o n u n d ru m to m ean, "How do
clients c h a n g e th eir th ou gh ts? How d o clients get them selves to
b e lie v e o n e th o u g h t and reject a n o th er? W h at does believe m ean ? Is
sh ifting beliefs sim p ly a m atter o f m echanical repetition and rein­
forcem ent, o r d o c h o ic e an d c o m m itm e n t have so m eth in g to do with
ch an g in g a n internal state su ch as cognitions?"
T h e p red ica m en t a b o u t h ow can a g h o st affect a m a c h in e is the
sa m e p red ica m en t a b o u t cogn itiv e therapy. How can clients change
th eir th ou gh ts? Even if o n e substitutes m ind for ghost o r b o d y for
m a ch in e, o r su bstitu tes ch oosing , believing, and intending for mind,
or n eu rotran sm itters, cortical and subcortical b ra in regions for body,
th e p ro b lem rem a in s the same.
Since it is im p o ssib le for the g h o st to m an ip u la te th e m achine, is it
not im p o ssib le for clients to c h a n g e their thou ghts? But clients do
c h a n g e th eir th o u g h ts all the tim e so th e re m u st b e s o m e th in g w rong
w ith th e theory, an d there is.
Ryle suggests that th e d ic h o to m y b e tw e e n m in d and m atter does­
n't exist a n d th at therefore th e p rob lem o f interface disappears.
H u m an ity does n o t live in tw o parallel worlds, o n e m aterial an d the
434 T h e N e w H a n d b o o k o i Co g n it iv e T h e r a p y T ec h n iq u e s

o th e r m ental, o r w h ere o n e is s u b je c t to m e ch a n is tic forces an d in v o l­

u ntary causes and effects and th e o th e r is su b ject to volition, choice,
purpose, and resp o n sib ility T h e tw o descriptions are sim p ly different
ways o f acco u n tin g for h u m a n beings. It is n o t th at o n e d escrip tion is
true and the o th e r is false, n o r is it true th at o n e is m o re useful than
th e o th er; each is useful in its ow n sphere. W h e n p rescribin g m e d ica­
tion for a seriously psychotic patien t it is useful to lo o k at th e physi­
cal— th e b io ch em ical in teractions and th e en tire ch ain o f c h em ical
causes and effects. But w h en co u n selin g a clien t a b o u t life decisions,
it is useful to lo o k at th e m en tal— the process o f decision m aking, life
purposes, a n d choosing. Ryle's statem en t b est su m m a riz es th e answ er:
"M en are n ot m achines, n ot even g h o s t-rid d e n m achines. T h ey are
m e n — a tau tolog y w hich is so m e tim e s w orth re m e m b e r in g " (Ryle,
1949, p. 81).

E x a m p le
I will m ak e the final ex a m p le in this b o o k , m y m o st p erson al e x a m ­
ple. It con cern s h ow I c a m e to accep t th e p h ilo so p h y expressed above.

W e d a n ce ro u n d in a ring a n d suppose,
But th e Secret sits in the m id d le and knows.
— Robert Frost (Lathem , 1975, p. 362)

Despite years o f study in psychology, as well as p h ilo so p h y a n d sci­

ence, m y u nd erstand ing o f th e c o m p le x ity o f h u m a n n a tu re didn't
c o m e from a n y o f m y b o o k s, research, o r years o f ed u cation . It c a m e
from a person al sou rce— m y father. It h ap p en ed this way.
M y dad has b e e n g o n e for m a n y years now, b u t 1 still th in k o f h im
often. He was an architect, th e typ e w h o loved th e art far m o re than
th e tech. He loved art so m u ch that h e eng aged in a fam ily ritual that
w'e kids hated ; ev ery o th e r S u n d ay or so h e w ould pile th e en tire fam ­
ily into o u r car, Old Bettsy, an d drive to so m e art sh ow o r m u s e u m to
see a new exhibit. He told m o m that it w ould b e g o o d for us kids, th a t
it would m a k e us cu ltu red o r Som ething, b u t h e really ju st w a n te d to
see th e sh ow h im s e lf a n d liked h a v in g c o m p a n y along.
Preteen kids are less th an e n th u siastic a b o u t m u sty art m u seu m s,
and w e w ere no exception, so w e sa b o ta g e d th e ex cu rsio n s in ever)'
way w e could, b u t o n e sh ow c a m e a lo n g th at w e c o u ld n 't get o u t of.
A Van G ogh e x h ib itio n was to u rin g th e c o u n tr y a n d h ad arrived at the
P hiladelphia Art M u seu m , so w h e n th e n ex t S u n d a y c a m e a r o u n d w e
Philosophical Underpinings 435

w e re p ou red into O ld Bettsy and taken to see it.

W h e n w e arrived at th e m u s e u m I spent m ost o f m y tim e trying to
find s o m e th in g interesting to do, to u ch in g the m edieval a rm o r and
lo o k in g at th e crossbow s. W h e n I could n't avoid it any longer, I went
inside to see th e exhibit.
As I w alked a ro u n d lo o k in g at the Van G ogh paintings, I im m edi­
a tely disliked them . To m y 10 -y ea r-o ld eyes they looked silly. The
flow ers didn't lo o k like flowers and th e farm had colors that no farm
has ev er had. Taken to g e th e r the paintings didn't lo o k real to m e; they
didn't sh ow w h at p e o p le see w h en th ey look at things. 1 concluded
th at Van G ogh could not draw.
N ear the end o f th e e x h ib it th ere was a painting o ff b y itself in a
place o f honor. Stand in g in front o f it was a grou p o f ad m irin g adults;
m y dad was a m o n g them . I was curiou s a b o u t w h a t these grow nups
th o u g h t was so special, so 1 stood b e h in d th e m and looked. It was a
p a in tin g o f a n ig h t scene, w ith a large sky ov erlookin g a sm all village.
T h e sky was a d ark rich blu e; th e village b elo w was sketched in o u t­
line. But th e m ost surprising th in g a b o u t th e p ain ting were th e stars.
T h ey w eren't dots o f light, b u t h u ge gold en spirals spinning in th e sky.
T h ey d o m in a ted and o v erw h elm ed th e painting.
I stared at it for so m e tim e b u t still had the sam e reaction I'd had
for th e o th ers— it didn't lo o k real. Stars don't lo o k like that; th e y are
dots o f light, n o t spirals, and the color o f th e sky was to o blue, the tex­
ture to o grainy. T h e w h o le th in g looked as if it had b e e n painted with
a shovel rath er t h a n a brush.
I w an ted to m ov e on an d find so m eth in g else to do, b u t then I
sto p p ed for a m om en t. M y dad and th e o th er adults were still adm ir­
ing the painting, and I r e m e m b e r thinking, "M a y b e I'm w ron g; if
e v e r y b o d y saw w h at I saw, n o b o d y would go to these exhibits. But
th e y do. M a y b e th ey see s o m e th in g I don't see. After all, I'm o n ly a kid.
W h a t d o I know ? If s o m e b o d y is m issing som ething, it's p ro b a b ly me."
So I stayed and tried to co m p re h e n d w h a t m y dad saw by m im ick­
ing the way that h e was lo o k in g at it. If h e stood with his w eight on
o n e leg, stroked his chin and said, "U m -hum ," th e n I did th e same. But
it didn't work. I kept o n th in k in g the sa m e th in g— a sloppy painting,
inaccu rate, unreal, p oorly drawn. M a y b e o th e r 10 -y ea r-old s could
h av e ap preciated its b ea u ty ; m a y b e o th e r boys were m ore sensitive,
insightful, artistic, o r profound, b u t I wasn't; I was ju st a typical 10-
y e a r-o ld kid, and I saw nothing.
T h e n m y dad asked m e w h eth er I liked it, and I knew 1 was stuck. If
I said w hat I felt, "I th in k it's dumb," I would h av e caused a big prob ­
4 . 3 f t _______________________________ T h e N e w H and bo o k of Co g n itiv e T h erapy T ec h n iq u es

lem. Dad and the o th er adults vwouId have regarded m e as a stupid,

b ratty kid w h o shou ldn't b e allowed into th ese ex h ib itio n s anyway,
and far m o re importantly, m y dad w ould h av e b e e n em barrassed. He
would have gotten angry, said, "The hell with it," and dragged us all
hom e. M o m would have b e e n hurt b eca u se th e fam ily o u tin g was
ruined, a n d m y b ro th er and sisters would have yelled at m e for upset­
ting M o m and Dad and ru in ing their day. T hey w ould have d e m a n d e d
that I b e left h o m e th e next time, and, alth o u g h I disliked m u seu m s, I
disliked b e in g left o u t o f th e fam ily even more. All this flashed th rou g h
m y m ind in a split second. Su d denly I b lurted out, "I like it . . . very
im pressive . . . n ice colors." Not a profoun d critique o f this fam o u s
painting, b u t the b est that I could d o at th e time. M y dad seem ed sat­
isfied; th e day was saved.
1 forgot all a b o u t th e painting for m a n y years, u n til I lived in Col­
orado. To escap e th e petty hassles o f city life I w ould so m e tim e s drive
into th e m o u n ta in s by m y self late at n igh t and ju st lie in a m o u n ta in
m ead ow lo o k in g up at th e stars. A round m id n igh t in th e high c o u n ­
try, th e stars sh in e brilliantly b e c a u s e th e air is so th in and th e city
lights are so far aw'ay. The sky is full o f th o u san d s o f stars th a t a p p e a r
to en v elop the earth. W h e n lo o k in g up at th e sk y from a high m o u n ­
tain pass, I was always co n scio u s o f h ow b ig th e c o s m o s is a n d how
sm all w e little h u m a n b ein g s arc.
O n e ev en in g I was lyin g in m y m e a d o w lo o k in g at th e stars w h en
Van G ogh's picture pop ped into m y m ind. Suddenly, after 2 0 years, 1
u n d ersto o d w hat th e picture m eant, w h y m y dad had liked it so, w h y
it was such a fam o u s painting. Van G ogh's Starr}' N ight captured th e
feeling o f that m o m en t, a feeling that I cou ld n 't h av e u n d e rs to o d at 10
b u t th at I could now. Van G ogh had painted a h u m a n b e in g 's e m o ­
tions o f w o n d er a n d aw e o f th e n ig h t sky.
W h y was th e picture u n d e rs ta n d a b le o n that m o u n ta in meadow,
b u t not b efore? A lot had h a p p en ed in the 2 0 years sin c e 1 h a d first
seen it. A stro n o m y h ad cau g h t m y interest, and b la c k holes, gaseou s
nebu la, a n d the im m e n sity o f th e u n iverse h ad im pressed m e. I had
studied p h ilo so p h y and d o n e a lot o f th in k in g a b o u t h u m a n nature
and a b o u t o u r place in th e cosm os, w h y w e are h ere an d h o w small
o u r earth is. So w h en 1 lo o k ed at th e stars in the m o u n ta in m e a d o w I
look ed at th em w ith new eyes and saw life in a way far b e y o n d w h at
I could have seen at 10. Technically, th ey w e re th e s a m e stars, b u t they
didn't feel th e sam e. T he stars 1 saw in th e m o u n ta in s o f C o lo ra d o felt
far m o re like Van G ogh's stars th a n th e stars I had se e n w h e n I was
Philosophical Underpinings 437

10. T h ey w ere h u g e sp in n in g galaxies, m ad e u p o f m illions o f stars and

p lanets and p ro b a b ly full o f team in g life, not ju st little dots in th e sky.
W h a t is h u m a n reality? W h ich is th e tru e picture o f th e sky: the
view o f a 1 0 -y e a r-o ld b o y or the view o f Starry Night? W h a t is the true
n a tu re o f ou rselves and o u r clients— th e m echanistic, determ inistic
side, o r th e freed om and responsibility side? W h e n young, I would
h a v e said, "Stars are dots, and p e o p le are people. W h at you see is what
you get." But as I got o ld er a n d th ou g h t m ore an d learned a n d felt
m ore, 1 realized, "Stars are th e universe, and p eople are m a d e o f star
stuff. W h a t you see is w h at y o u r u nd erstand ing en a b le s you to see."
H u m a n n a tu re is not simple. It exists in m a n y layers that change,
m ove, an d develop constantly. T he top layer is o n e o f sim p le ap p ear­
a n c e — w h a t w e se e w h en w e look, w h at I saw w h en I was 10. T h e b o t­
to m layer is o n e o f deep m e a n in g and u nderstand ing— w hat Van
G o g h painted, w h a t w e feel o n a m o u n ta in meadow, w h a t w e notice
a b o u t o u r ow n nature. O u r e x p e rie n ce o f living in the world forges
this layer. T he a s tr o n o m e r sees spiral galaxies, quasars, pulsars, black
holes, a n d stellar m echanics. T he astrologer sees con stellations and
c o sm ic d eterm in istic forces in flu en cin g h u m a n nature. The ship's cap­
tain sees m eridians o f longitu de and latitude. T h e m inister sees the
creativ e p ow er o f G od gu iding hum anity. In th e b o tto m layer, w e don't
see w h at w e get; w e get w h at w e see.
So, w h ich is th e real sky, and w h at is o u r true nature?
All o f them . It sim p ly d ep en d s u p on the way w e lo o k at it.
After all m y years o f co u n selin g w ith m y fellow h u m a n beings, I try
to r e m e m b e r th a t th ere are m a n y layers o f h u m a n nature, and I strive
to u n d erstan d th e layers th a t m y clients are experiencing. I know that
s o m e clients are trapped on the surface and need to go d eep er to feel
happier. T h ere are no right or w ro n g layers, b u t th ere are m o re help­
ful and less helpful w ays to lo o k at things. W h e n I cou n sel clients w ho
see o n ly dots in th e night sky, I attem p t to sh ow th em that hidden
inside th e dots are swirling, m u lticolored galaxies dancing in the
starry' night.

C om m en t
T h e read er d o e s not h av e to sh a re th e au th o r's philosophical
u n d e rp in n in g s to practice th e cogn itive th era p y expressed in this
b o o k . C ognitive restructuring therapy is a large en o u g h ten t to
en c o m p a ss differing views.
438 T h e N e w H a n d b o o k o f C o g n it iv e T h e r a p y T e c h n iq u e s

F u rth er In fo r m a tio n
The reader will have his or h e r ow n favorite p h ilosop h ical sources.
S o m e o f m in e are: Bertrand Russell, A Histor}' o f Western P hilosophy (1945)
and Hie Basic Writing o f Bertrand Russell (1961); Jo h n Stuart M ill, Philosophy
o f Scientific M ethod (Mill, 1950); Q u in e and Ullian, The Web o f B elief (1978);
G ordon Ryle, The Concept o f M ind (1949); W ilson, Language an d the Pursuit
o f Truth (1967); and W ilson, Thinking w ith Concepts
 /

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 X

v
v

\
 /

Subject Index

A-B-C theory, com plete formula, 8-11 a priori thinking, 198

abuse, physical, 104-6, 268, 304-5 assaults, hidden cognitions preceding,
see also sexual abuse 69-70
acceptance-integration model, 552-55, assertion
com bined w ith cognitive treatment,
559
achievem ent need, see perfectionism 96-100
addiction, 66, 67, 70, 74, 87, 91-92, 98-99, images, 251
204, 303-4, 350-75, 411-14, 416 self, w ith, 96-100
see also alcoholism ; drug abuse; drug
assertions, client's claims, 180-81
dependency attacking beliefs, 21-25, 92-96
attitudes, see beliefs
adolescence, 3-5
agoraphobia, 1-6, 52, 86, 141-42, 21^-16, attribution, 58-60, 271, 337, 403-10
278-80, 400-402 auditory practice, countering, 309
see also anxiety'; phobias
autom atic thoughts, 65
aversive conditioning, 121-25
aha experience, 237
negative labels, 124, 267
alcoholism
cognitive map, core beliefs, 87 physical, 123
fam ily, alcoholic, 299-300 red taping, 123-24
rem oving positive stim uli, 124
group therapy, for, 411-15
self-punishment, 121-22
self-efficacy, 43
standard images, 122-23, 251
typical lifeline, 190
avoidance conditioning, 128-133
see also addiction; drug abuse; drug
dependency
bad behavior, defined, 184-87
altered states, 156-58
basic perceptual shift, see perceptual
images, 252
shifting
interpretation, 163-66
behavior therapy, 76, 311, 384, 432
am biguous pictures, 218, 220, 227, 230,
231,242 beliefs
abstract vs. concrete, 182-83
analogies, see fables
analytic philosophy, 193-94 analyzing, 187
best possible, 154
anecdotal evidence, 199
coping, 140-43
anger and aggression, 69-70, 204
core, see core beliefs
anticatastrophic reappraisals, 136-40
d aily lists of Bsr 29
anxiety, 91, 204
deciding true or false, 192-93
counterattacking, 95-96
defining, 182-83
dissonance, and, 110
drug dependency, 364-70
finding the good reason, and, 204
finding the m eaning of, 183-87
free floating—generalized, 52
forcing choices, 102-10
presentation, 137-39
historical roots, 276-77
see also agoraphobia; phobias; social
list o f cultural beliefs, 404-5
phobias
474 ..... S u bje c t I ndex

lists o f critical life Bs, 81-82 coping '

master)', 250 images, 140, 250, 253
melted wax theory, 92 sm all detail images, 250, 254
nonadaptable, 303 statements, 140-43
preform al, 296 core beliefs, 76-80, 182, 515, 337, 405-5
primacy, 163-64, 289-98 core com ponents, o f cognitive therapy,
rational, 167-69 385-88
reference groups, for, 392-93 corrective images, 251
resynthesizing, 276-306 correlations, looking for, 187-93, 191-92
specific lists o f Bs, 278 counselor style, xi-xiii, 577-78, 411-14,
survival and, 301-6 415-16, 418-23
turning into statements, 180-81 counterconditioning, 135-34
valid ity of, 425-31 countering techniques
biofeedback, 134,323-326 attacking, 92-95
blam ing, and fault finding, 196 covert relaxed, 153-36
brain disputing, 100-102
cartoon image, 19 hard counters, 88-131
brain w ave patterns, 156-58 objective counters, 159-207
bridging, 256-75 logical, 162-65
art of, 258-59 soft counters, 132-58
crisis intervention, 329 theory, 88
higher order, 269-75 covert conditioning
label, 266-69 avoidance, 128-31
perceptions, 258-62 extinction, 143-49
values, 262-66 higher order, 269-75
brief therapy, cognitive restructuring, 330 reinforcem ent, 155-55
covert relaxed countering, 133-36
card technique, use in countering, 167-68 crim inal behavior, 504-5
cartoons crisis intervention, use o f cognitive ther­
brain, the, 19 apy in, 328-31
therapeutic, 35 adapting techniques to, 330-31
used in therapy, 33-34 b rief cognitive restructuring, 350
catastrophic thinking, 134-36 m arathon session, 529
cathartic images, 252 quick perceptual shift, 529
challenging beliefs, see disputing critical life events, 81-82, 277-85, 294
childhood experiences, 23-25, 289-98 criticism , handling, 11
chronological beliefs, 277-280 culture, cognitive therapy, and
class consciousness, 160, 162-63 core cultural beliefs, 403-10
client-centered therapy (Rogerian), 384, counseling in different cultures, 410-17
384-385, 452 cultural categories, 396-405
cognitive behavior m odification, 14 cu ltu rally approved diagnosis, 304-5
cognitive deficits m odel, 332, 338 influence on beliefs, 292-94
cognitive developm ent theory, 276-307 reference groups, 592-93
cognitive dissonance, 110-15 stories and fables, cultural, 417-24
cognitive map technique, 84-85
cognitive restructuring therapy, develop­ dating anxiety, 2
ment of, 1-6 defining beliefs, 182-83
com m itm ent, im portance in therapy, dependency, 189
192-93 depersonalization, 171-74
com pulsive behavior, 315-319 depression, 91-92, 179
computer, 34
determ inism vs. free w ill, 452-34
conceptions, see beliefs; perceptual developm ental theory
themes o f beliefs, 82
concepts, finding the m eaning of, 185-87 o f self-concept, 47-48
see also beliefs; perceptual themes
diagnosis, cu ltu rally approved, 304-5
conditioning, 116, 125-26, 145-44, 147-48 d iary research, 65-69
269-72
D IBs (disputing irrational beliefs), 178-79
consonance, 110-115
dichotom ous thinking, 196
contingency vs. contiguity, 118-19 * disease concept, 149-53
Subject Index,.
/

disputing and challenging, 100-102 impressing w ith large number, 202

dissociation, see depersonalization ipse dixit, 199
dissonance, see cognitive dissonance logical, 194-205, 205-207, 271
divorce and separation problems, 73-74, musterbation, 196-197
407-8 m ystification, 199
see also relationship problems permatizing, 195-96
dreams, 18, 211 psychologizing, 197
drug abuse reification, 197
causes, 550-51 self-righteousness, 201
cognitive influence, 351 slippery slope, 198
theory, 575-75 socialized thinking, 200
see also addiction; alcoholism tried and true, 202
drug dependency fam ily, influence on beliefs, 298-500
causes, 551-54 fantasy, see fables
client m anual, 364-70 fear of
cognitive form ula, 554-56 autom obiles, 280
counters to beliefs, 564-70 being alone (m onophobia, autopho­
key cognitive factors, 562-65 bia), 85, 295
theory, 575-75 chairlift, 260
therapist's style, 570-75, 411-15 death (thantophobia), 112-15
see also addiction; alcoholism
disease (pathophobia), 112-15
fainting, 94-95
flying (acrophobia), 278-80, 511-15
earliest recollections, 289-98
efficacy expectation theory, 45-51, 140, unconscious, 151-52
w ater (hydrophobia), 147-49
271
see also specific phobias
egocentric error, 198
emergencies, see crisis intervention fear, realistic (appropriate), 177
flim -flam (fooling ourselves), 545-47
em pathy, 252, 254
environm ental practice, 515—19 flooding
escape conditioning, 125-28 cognitive, 116-21
anxiety relief, 127-28 focused, 117
relief from aversive state, 127 hierarchy, 117
image, 116-17
esteem, self, 50
negative practice, 117
evaluations, 60-64, 271
verbal flooding, 117
evidence, m eaning of, 187-88
existential therapy, 109, 452-55 focusing, vii
cognitive, 576-85
expectations, 58-45
general focusing, 576-77
explanatory style, 72-75, 556-57
specific procedure, 578-80
extinction, 161-66
G endlin's method, 584-85
behavioral in vivo, 144
Ellis's style, 577-78
belief, 144-45
form ula, basic, 8-11
covert, 141-49
future perspective images, 251
neutral images, 145
shaped covert, 145-46
gestaltens, 76,
time, 145
see also perceptual themes
graph analysis, 187-94
fables, 417-24
group cognitive therapy, 54, 411-15
failures, therapeutic, 588-91
guided practice, 525-27
fallacy
guilt, 184-87
ad hom inem , 199
anthropom orphism , 195
handicaps, coping w ith, 25-26
appeal to ignorance, 205
handouts, client
avvfulizing, 196
core cultural beliefs, 404-05
begging the question, 202
different types of beliefs, 57-8
correlation and causation, 200
explanation of services, 150
entitlem ent, 197 how hum anity learned its beliefs, 502
finding the good reason, 205-7
how to look at things in new ways,
forestalling disagreement, 202
222-25
ignoring counter evidence, 20
476 S u b j e c t In d f x

objective countering, 161 leveling images, 253

selective memory, 56 linguistic analysis, 184-87, 193
transform ation rules, 228 lifelines, graphs, 189, 190
w h y As aren't everything, 27 life themes, 80-84, 276-78, 285-89
hatred o f m ankind (m isanthrope), 259 linguistic philosophy, 180
higher order conditioning, 269-72 linguistics, 180
history lists, o f Bs
beliefs, of, 276 core cultural beliefs, 404-5
early recollections, 289-98 critical life events, 81-81, 285
fam ily beliefs, 298-500 d a ily lists, 29
life themes, 285-89 life themes, 285-89
resynthesizing, 276-85 specific lists, 278
hom ework logical analysis, theory, 180-94
ABCs, d aily lists, 29 love, loss of, 5, 179, 264, 347-49
first session, 15 see also relationships
hierarchy o f values worksheet, 265 low probability visualizations, 251
perceptual shift worksheet, 212
resynthesis worksheet, 294 M e M u llin -G eh lh aar Addiction Attitude
hom ocentric error, 198 Test (M G A A ), 558-565
hostility, see anger and aggression m anuals, use in cognitive restructuring,
hyperpersonalization, 171-74 31-52, 554-55, 564-70
hypnosis, and cognitive therapy, 157 maps, cognitive, 84-86, 557
hypochondriac, 118-20 m arathon session, 529
marriage, 57, 405-7
idealized images, 250-51, 254
master list o f beliefs, 82, 294-95, 501, 310
images, 249-55
mastery vs. coping images, 140, 250, 254
blowup, 251
medical m odel, 149
difficult, 228-41
memory, selective, 55-58
hidden, 224-28
metaphors, see fables
images, fanciful, 154-55, 252 misanthropy, 259
progressive image m odification,
mistakes, coping with, 97-98
241-44
m odel and contrar)' cases, 184-87
psychotic patient, w ith, 555
m odeling images, 250, 254
rational em otive, 245-48
m onitoring client progress, 586-88
resynthesizing early beliefs, in, 290-91 M orita therapy, 146, 149
reversible, 219-24
myths, see fables
3 -D ,240-41
see also individual i m a g e s nature tapes, 157
im m oral behavior, definition o f 184-87 negative consequences images, 252
inductive reasoning, 187 negative reinforcing images, 252
inferiority feelings, 284, 400 neuropsychology, 20, 452'
insight, 336-38 noxious images, 250, 253
instrum ental conditioning, see operant nursery rhym es, see fables
conditioning
instructions, self, 64-68 obsessions, 172, 174
intuition, 173-74 operant conditioning, 155
irrational thoughts, see beliefs overgeneralization, 195, 595-96
overprotection, 86
JRA s, 39-41, 46 overpowering, 198
labeling, 266
pain, coping w ith, 12
label shifting, 266-69
panic attacks, 1-6
labels, sym bolic, 268
cognitive map, 86
Langton test for drug abuse vs. depend­
graph analysis, and, 188-89
ency, 556-58
paradoxical techniques, 115, 450-51
language vs. images, 249-50 paranoia, 429-51
learned helplessness, 72
parsimony, law of, 197, 425-51
lessons
pathological and nonpathological think­
show ing that Bs cause Cs, 11-12
ing, 149-55, 196
teaching the basic form ula, 8-11 *
patterns, see perceptual themes
 477
Subject Index
/

Pavlovian conditioning, see conditioning public vs. private view points, 175-78
payoffs, see reinforcem ent punishm ent, 305
see also aversive conditioning
perceptual shifting
assum ptions, 209-10
quantum leaps, key elements, 232-38
basic, 211-16
bridging, 256-75 flexibility, 236-37
crisis intervention, 529 guidance, 236
difficult transpositions, 228-41 repetition, 237-38
focusing, 376-85 time, 237
willingness, 235-36
forcing, 102-10
quick perceptual shifts, 329
key elements, 235-58
origins, 232-33
progressive transposition, 341-44 rational beliefs, 167-69
rational em otive behavioral therapy,
stories and fables, w ith, 418-24
100-102, 178-79, 245-48
theory, 208-11
see also Ellis, A.; specific techniques
transposing images, 218-27
rational em otive im agery (RED, 245-48
perceptual themes, 210-11
rationalizations, 206-7, 304
perfectionism , 39, 196, 324
see also fallacy, finding the good reason
philosophical foundations of C RI
w hat is rational, 425-31 reality, 432-38
reality therapy, 110
w h at is real, 432-38
reconceptualizing images, 251
phobias
foreigners (xenophobia), 393-96 red taping, 123-24
insanity (lyssophobia), 106-9 reinforcem ent
losing control over emotions, see ago­ covert, 153-56
raphobia external, 155
standard reinforcing images, 154-55
low probability events, 177
reference groups, and beliefs, 392-93
not being anxious (Harold), 213-14
relationships, 44-45, 73, 93-94, 104-6, 179,
open or public places, see agoraphobia
204, 264, 268, 347-49, 405-7
people (apanthropophobia), see social
relaxation
phobia
guided practice, in, 323
wom en (gynophobia), 93-94
images, 250
see also agoraphobia; fear
positive reinforcem ent, see reinforcem ent instruction, 157
types, 132
practice techniques
religious conversion, 232-33, 262
auditory, 309
resistance, 343-48
d iary research, 319
resisting tem ptation images, 253
environm ental, 315-19
respondent conditioning, see operant
guided, 323-27
conditioning
reason for, 307
responsibility, excessive, 38, 39, 129
role-playing, 310
see also guilt
visual, 308-9 resynthesis, beliefs, 276-306
pragmatism, 171, 301, 303-5
rew arding images, 251, 253
prediction o f success in CRT, 385-88
rewards, see reinforcement
preventive treatment, 252
role-playing, 309-14
prim acy, rule of, 163-64, 289-98
romance, see relationships
probability, 427 Rum plestiltskin effect, 269
progressive image m odification, 241-45
psychodynam ic therapy, 77, 151-52,
sabotages, clients, 340-49
297-98, 384
counter sabotage, 341_
psychosis exposing the play, 343
explanatory style, 74-75
finding payoffs, 342-43
fear of, 320-23 preventing sabotages, 342
m anic and lithium , 190-91
types of, 540-41
paranoia, 429-31
see also resistance
self-efficacy, 43 n
satiated images, 252
see also seriously m entally ill (SM U
schema-focused therapy, 289
patients
schemata, cognitive, 210-22
PT5D, 53, 278
478 S u b je c t Ird lx

scripts and therapist's instructions v Bob (paranoid), 429-31

bridge philosophy to reduce fear, boxing coach, 24
260-61 Burt (cocaine addict), 98-99
counterattacking w ith force, 94-95 Carol (cancer phobia), 112-15
creating em otions w ith im agination, Chad (depressed, felt inferior), 243-44
15 cove o f black pearls (challenge super­
different thoughts about the same sit­ stitions), 419-22
uations, 21-22 C ynthia (dysfunctional fam ily), 48-49
escape conditioning, 127 D aniel (fear o f going insane), 106-9
finding hidden cognitions, 71 D aphnia (guilt), 184-87
lim its o f thought control, 30 D avid (anxiety attacks), 320-23
m elted wax theory, 92 Dean (presentation anxiety), 137-39
preventing sabotages, 342 Delm a and Suzanne (divorced), 73-74
relaxed countering, 135-36 Denise (agoraphobic), 214-16
relaxed desensitization, 134 Diana (selective m em ory about m ar­
self-punishment, 122 riage), 57
standard aversive image, 122-25, 253 D yirbal aboriginal tribes, 396-99
teaching the basic form ula, 8-11 Ed (unknow n panic attacks), 1-6
w hen is fear reasonable, 177 Fred (injected thoughts), 16-18
words, abstraction level, 182-83, 399 John (com pulsive), 315-19
security images, 252 Jo h n n y (pow er o f the mind), 28-30
self-concept, 46-51, 271
Justin (psychological hypochondriac),
self-help books, 32-33 118-20
self-sacrifice, 305
Karen (deteriorating athletic perform ­
semantics, and analyzing beliefs, 396-403 ance), 224-26
sensationalism , 195
Kate (abusive husband), 104-6, 109
seriously m entally ill (S M I) patients K evin (panic attacks), 146-48
acceptance-integration model, 332-33 Lester (relationship problems), 580-84
cognitive deficits model, 332, 338 Lynn (fear o f flying), 311-13
explanatory style, 74-75 M arin a (afraid o f being alone), 83
m anic and lithium , 190-91
M ark (agoraphobia and fear o f flyin g)
paranoia, 429-31 278-80
self-efficacy, 43
M artha (fear o f emotions), 400-402
stress reduction m odel, 332, 358
M artin (m ultible problems), 324-27
sexual abuse, 49, 69-70, 189, 264, 268, 304
M ary (perceived intellectual inferior­
sexual problem, 183-84
ity), 284-89
sibling rivalry, 261
M au rice (relationship problems),
sidetracking, 201-2 347-49
slides, use o f in therapy, 33
M ika (flim flam), 342-47
social phobia, 78-79, 89, 137-39, 238-40 M ike (spoiled), 44-45
264, 295
M argo (angry, blam ed parents), 246-48
Socratic questioning, 88
M oth er Teresa (causes o f poverty)
spoiled behavior, 279
257-58
sports psychology, 224-26
m y father (Van Gogh's "Starry N itjht")
stimulus-response theory, see conditioning 434-37
stress, see anxiety; phobias
Nigel (alcoholic), 355-56
stress reduction model, 332, 338
Paula (agoraphobic), 151-42
stories, client's/therapist's Ph ilip (shy w ith wom en), 93-94
Al (low self-esteem), 41-42
quantum leaps, 232-33
Albert (underachiever), 82
Renee (anti-Am erican), 292-94
alcoholics' lizard, 366-66
Richard (depression, loss o f love), 179
Alex (dating anxiety), 272-75
Ronald (unidentified anxiety), 280-83
Anna (Nazis atrocities), 24-25
Roy (religious conversion), 253-54
auto m echanic (bridging), 257-58 run to the roar, 90-91
Barton (lack o f trust), 313-14
Sara (passive), 99
Bess (afraid o f fainting), 94-95
Terr)’ (social phobia), 238-40
B elli (fear o f unconscious), 151-52
subjective error, 198
Betsy (fear o f positive emotions),
substance abuse, see drug abuse; drug
62-63 »
dependency
Subject Index
/
success, see perfectionism true love, 292, 405-07
success in CRT, prediction of, 585-88 trust, lack of, 430
ultim ate consequences images, 251
tapes, audio and video used in therapy,
unconscious, 2, 151
33, 97 utilitarian counters, 169-71
teacher, inner, 98
tim e-tripping images, 253 values
transcripts o f counseling sessions bridges, as, 256-57
addiction group counseling, 411-15 hierarchy of, 262-66
Bs cause Cs, 3-5 visualization, see images
cognitive focusing, 380-84 visual practice, 270, 308-9
coping w ith agoraphobia, 141-42
weight control, 11-12
counter sabotage, 341-42
words
difficult transpositions, 238-40
aversive conditioning, and, 124
drug dependent client, 371-73
level o f abstraction, and, 182-83
fear o f chairlift, 260-61
see also language vs. images
fear of flying, 311-13
worksheets, client
Freud's counseling leads, 297-98
ABCs, d aily lists, 29
lack o f trust, 313-14
first session, 13
psychotic patients, 335-36
hierarchy o f values worksheet, 265
public speaking anxiety, 79
perceptual shift worksheet, 212
transform ation rules, 228
resynthesis worksheet, 294
transposing beliefs
difficult transpositions, 228-41 xenophobia, 393-94
progressive m odification, 241-44
zero reaction images, 252, 253
transposing images, 218-28
'

*
 Author Index

Abrahm s, E., 102, 447 Barker, W „ 57, 442

Ackerm an, R., 195, 459 Barlow, D„ 125, 128, 441, 445, 452, 471
Adams, H „ 23, 156, 444, 448, 464 Barnard, P., 12, 195, 468
Adams, N „ 46, 145, 440 Barrett, R., 275, 456
Adam son, B., 575, 459 Barry, D „ 207, 441
Adler, A., 289, 459 Baum bacher, G., 216, 441
Agras, W „ 125, 441 Beattie, O., 84, 441, 445
Ajzen, L., 166, 448 Beatty, J., 158, 441
Alberti, R „ 100, 459 Beck, A., ix, 6, 12, 56, 53, 58, 65, 67, 72, 80,
Alexander, P., 500, 439 84, 87, 96, 140, 148, 156, 163, 166, 178,
Alford, B., 67, 96, 459 199, 216, 305, 534, 551, 575, 591, 459,
Anderson, F„ 469 441, 449, 471
Anderson, ]., 193, 241, 439 Beck, J., x, 53, 67, 80, 156, 165, 505, 310, 441
Appelbaum , P., 539, 458 Becker, R„ 306, 456
Apperson, L., 559, 458 Beckham, E., 591, 446
Arakaw a, 403, 455 Bedrosian, R., 500, 442
Arkowitz, H., 84, 449 Beebe, J„ 585, 450
Arnkoff, D „ 145, 457 Bellezza, F, 266, 442
Arnold, M ., 96, 459 Benedict, R., 338, 442
Aronson, E., 115, 439 Berger, ), 227, 442
Bergin, A., 143, 442, 457
Arts, W „ 125, 455
Ascher, L„ 128, 148, 459 Berne, E„ 84, 442
Assafi, 1., 25, 51, 55, 155, 216, 527, 458 Berns, S., 338, 455
Bernstein, M., 55, 57, 442
Attneave, F„ 227, 439
Aubut, L„ 156, 440 Beutler, L., 84, 449
Beyerstein, B., 158, 442
Austin, G., 193, 443
Bilodeau, A., 338, 444
Avison, W., 338, 440
Binder, J., 289, 442
Ayer, A., 169, 193, 440
Birchw ood, M., 338, 359, 442, 444, 446
Azrin, N „ 131, 440
Bistline, J., 156, 442
Black, A., 151, 453
Baer, J., 375, 440
Blackburn, 1., 338, 461
Bajtelsm it, J., 156, 440
Block, J., 227,241,442
Baker, S., 25, 440
Bakker, T„ 91, 440 Blum , K., 375, 442
Bobbitt, L., 60, 75, 442
Banaji, M ., 266, 440
Bohm an, M „ 575, 442, 444
Bandler, R., 149, 275, 549, 425, 440, 446,
Boring, E„ 218, 227
451
Bandura, A., 43, 46, 53, 140, 158, 165, 519, Bo tw in ick ,)., 442
Boudewyns, P., 121, 442
423, 440, 441
Bourne, L., 195, 452
Barab, P., 55, 423, 440
482 A uthor In d e x

Bower, G., 195, 469 Cohen, S.,'275, 468

Bowers, M., 336, 442 Colem an, V., 194, 444
Bowler, P., 193, 207, 451 Collins, J., 391, 446, 466
Bozicas, G., 500, 442 Connella, J., 244, 454
Bradley, D„ 85, 442 Corrigan, R „ 60, 445
Brecosky, J., 339, 458 Corsini, R., 514, 349, 445, 463, 469
Brehm , J., 115, 169, 442, 470 Coursey, R., 339, 445
Brenner, H., 339, 443 Cox, R „ 268, 269, 409, 445
Breuer, J., 297, 443 Crooke, W., 424, 445
Brick, J., 148, 470 Csikszentm ihalyi, M., 84, 445
Bricker, D „ 84, 216, 514, 443 Cummings, A., 262, 423, 457
Brill, A., 297, 443
Brimer, C., 131, 455 Dallenbach, K „ 227, 250, 445
Brom ley, D., 50, 443 Dalyell, )., 424, 445
Brown, B., 158, 443 Damasio, A., 20, 23, 445
Brown, C. W „ 195, 443 Danaher, B., 156, 457
Brown, P., 266, 454 Dattilio, F., ix, 87, 300, 351, 445, 449, 462,
Brownell, K „ 125, 128, 443, 452 463
Bruhn, A „ 289, 290, 298, 443 David, A., 539, 445
Bruner, J., 195, 266, 443, 467 Davidson, P., 136, 445
Brunn, A., 156, 443 Davie, M „ 396, 468
Buchanan, G., 75, 445 Davis, K„ 162, 445
Bugelski, B„ 244, 445 Davis, N „ 36, 465
Buglione, S., 56, 443 Dawson, M „ 538, 461
Bulfinch, T., 424, 445 Deffenbacher, J., 14, 459
Burck, H., 36, 444 de Haan, E., 125, 455
Burns, D„ 32, 445 Deitrich, R., 375, 445
Butler, P, 100, 443 DeLozier, J., 275, 445
DeNike, L„ 43, 467
Cacioppo, J., 166, 266, 462 De Quieroz, E., 425, 445
Calhoon, B „ 156, 455 de Villiers, P., 131, 446
Callahan, E., 125, 441 DeVito, A „ 443, 469
Cameron, N., 171, 446 De Voto, B „ 469
Cameron-Bandler, L., 275, 446 Dewey, J., 171, 446
Cam pbell, B„ 56, 459, 464 Dewolf, R „ 36, 449
Cam pbell, D„ 166, 459 DiGiuseppe, R „ 72, 102, 351, 447
Cancienne, J., 58, 444 D ills, R., 275, 446
Cannon, W., 145, 444 D iM attia, D., 102, 577, 446, 447
Capelli, C., 538, 444 Dince, VV„ 158, 468
Carlson, J., 156, 158, 333, 444 Dobson, K „ x, 87, 244, 391, 446
Casey, B„ 15, 14, 19, 23, 31, 35, 35, 100, Docherty, J., 391, 446
125, 155, 156, 327, 410, 444, 458, 361 Dolan, R „ 591, 466
Cassidy, J., 338, 444 Donnell, C., 58, 459
Cassues, J., 385, 450 Donnelly, C., 423, 446
Cautela, J., 125, 128, 143, 148, 156, 432, Douglas, E „ 558, 453
439, 444 Drury, V., 539, 446
Chadwick, P., 338, 444 Dryden, VV„ 64, 102, 447
Chandler, G „ 36, 444 Duhl, B., 425, 446
Chapm an, S., 23, 31, 35, 155, 216, 327, 458 Dumas, 423, 446
Chase, P., 115, 465 Dunham , H. J., 191, 192
Chemtob, C., 53, 444 Dunlap, K „ 121, 446
Cheng, P., 60, 444
Dyck, M „ 155, 166, 452
Cipher, D., 25, 444 Dyer, W „ 32,446
Clark, J., 157, 444
Clarke, J., 351, 375, 444
Easton, M ., 338, 444
Cloitre, M ., 58, 444
Edwards, D „ 290, 298, 446
Cloninger, R „ 375, 442, 444 Eimer, B., 12, 449
Clum, G „ 36, 451 Eisler, R„ 457
Cochrane, R., 339, 446 * Elkin, I., x, 591, 446, 466
Author Index.
/

Ellis, A., ix, x, 6, 10, 12, 13, 32, 33, 36, 61, Friedman, M., 396, 403, 457
64, 72, 87, 96, 101, 102, 140, 163, 169, Frijda, N „ 269, 449
170, 179, 199, 203, 216, 245, 246, 248, Frost, R„ 434
300, 309, 310, 322, 334, 351, 375, 377, Fujita, C., 149, 449
409, 446, 447, 458, 461
Ellis, W „ 227, 447 Gallant, D„ 351, 449
Em ery, G „ 53, 58, 87, 96, 140, 178, 441 Garcia, J., 131, 449
Emmons, M., 100, 439 Gardner, M „ 203, 349, 449, 450
Engum , E„ 156, 447 Garfield, S., 143, 457
Erdm an, 11., 36, 466 Gates, VV„ 417, 454
Erickson, M „ 84, 158, 349, 448 Gauthier, J., 121, 457
Erickson, R., 338, 468 Gazzaniga, M., 96, 115, 465
Ernst, D., 153, 166, 452 Gehlhaar, P., 25, 31, 35, 70, 358, 559, 560, 361,
Escher, M „ 228, 448 363, 364-70, 571, 572, 373, 575, 459, 459
Everett, G „ 339, 458 G elle r,)., 339, 358
Eysenck, H., 391, 462 G endlin, E„ 255, 584, 385, 450
Genest, M „ 14, 23, 459
Fagan, M „ 314, 448 Gerrity, E„ 596, 403, 457
Falger, V., 306, 469 Gershm an, L„ 156, 440
Farber, 1., 43, 448 Ghiselli, E„ 195, 443
Fearnside, VV„ 448 Gholson, B., 43, 450
Feder, B „ 314, 448 Gifford, E., 128, 151, 339, 452, 470
Feixas, G., 36, 460 Giles, T„ x, 79, 87, 156, 216, 249, 327, 341, 391,
Fernandez, E., 23, 444 450, 459
Fernandez-Dolls, J., 405, 449, 464 Gillham , J., 50, 466
Fernberger, S., 226, 227, 448 Gillison, G., 50, 466
Festinger, L„ 115, 203, 448 Glass, D„ 591, 446, 466
Fezler, W „ 15, 23, 157, 454 Glasser, W., 110, 450
Fiedler, K., 403, 466 Glazer, U „ 148, 450, 451, 470
Fiester, S., 391, 446 Goetsch, V., 45, 470
Fine, M „ 300, 465 Goffman, E„ 349, 350, 451
Fishbein, M., 166, 448 Goldfried, M „ 143, 451
Fisher, G „ 220, 227, 242, 448 Golding, ]., 266, 454
Fiske, S., 174, 468 Goldstein, M., 338, 461
Flanagan, C., 84, 216, 314, 443 Golem an, D., 156, 451
Flannery, R., 156, 448 Goodnow, J., 193, 445
Flem ing, B„ 96, 449 Goodw in, D., 575, 451, 465
Flem m ing, D., 266, 448, 449 Gordon, A., 121, 447, 457
Floyd, M., 36, 467 Gordon, D., 262, 423, 451
Foa, E., 58, 459 Gordon, ]., 64
Folkes, V., 60, 451 Gotestam, K., 148, 451
Folkm an, S., 143, 455 Gould, R., 36, 451
Follette, V., 131, 452 Graham , R., 100, 463
Foree, D., 131, 448 Graham , S., 60, 451
Fornander, A., 424, 448 Granvold, D„ 460
Forrester, G., 140, 464 Greenberg, L„ 314,450,451
Forsterling, F., 60, 464 Greenberg, R., 53, 87, 96, 140, 178, 441
Fovvles, D., 153, 448 Greenfeld, D „ 536, 451
Foy, D „ 87, 448 G reenstone,)., 330, 451
Frank, A., 31 Gregory, R., 25, 227, 451
Frankl, V., 50, 31, 109, 448, 449 Greist, ]., 36, 466
Franklin, R „ 349, 449 Grieger, R., 102, 140, 447
Grinder, J„ 149, 158, 275, 549, 423, 440, 446,
Franz, R., 373, 575, 456
Free, M „ 56, 449 451, 460
Freeman, A., ix, 12, 36, 87, 96, 300, 331, Grof, S., 156, 451
439, 441, 445, 449, 462, 463 Gross, D., 53, 444
Guidano, V., x, 50, 51, 79, 80, 84, .349, 385,
Freter, S:, 359, 458
Freud, S., 199, 297, 443, 449 451, 452
Freund, P., 424, 449 Guse, S., 375, 451
484 A u t h o r . I n dex

Haaga, D„ 153, 166, 452 Jaycox, L „ 50, 466

Hafner, J., 334, 460 Jellinek, E„ 362, 455
Hake, D„ 131, 440 Jerom e, L., 409, 459, 470
Ilallberg, E„ 262, 425, 457 Johnson, B., 58, 262, 468
Ham ada, R., 55, 444 Johnson, D „ 1^5, 455
Mamm ill, K „ 559, 458 Johnson, J., 75, 131, 465
Hardy, A., 46, 145, 440 Johnson-Laird, P., 195, 469
Harper, R „ 15, 32, 53, 64, 102, 170, 447 Joyce, K., 228, 455
Hatcher, C., 314, 452 Juster, 11., 45, 64, 140, 452, 464
Hauck, P., 21, 25, 64, 72, 100, 452
Havens, R„ 158, 549, 425, 452 Kam in, L., 151, 455
Hawkins, R„ 46, 115, 319, 452, 465 Kanner, A., 145, 455
Hayes, S., 46, 125, 128, 151, 194, 519, 339, Kazdin, A., 128, 454
445, 452, 458, 470 Keenan, J., 266, 454
Haygood, R „ 195, 452 Kelleher, R „ 275, 454
Hays, P., 416, 423, 452 Keller, A., 596, 468
Hedberg, A., 156, 445 Kellerm an, II., 455
Heim berg, R„ 45, 64, 140, 452, 464 Kelley, H „ 60, 454
Herm an, S., 54, 461 Kelly, G., 51, 454
Hermansen, L., 375, 451 Kenardy, J., 34, 461
Herm stein, R., 131, 452 Kendall, P., 87, 244, 500, 446, 454, 456
Hersen, M., 457 Kidd, R „ 174, 467
Hewstone, M., 466 Kim ura, R., 417, 454
H ill, W „ 218 Kingdon, D., 558, 454
Him elstein, P., 514, 452 Kirker, IV., 266, 465
Hineline, P., 151, 452 Kirsch, 1., 25, 158, 440
Hobson, A., 211, 455 Kirsch, K., 456
Hollon, S., 456 Kitayam a, S., 405, 454
Holt, S., 266, 442 Klein, M., 56, 585, 450, 466
Holther, VV„ 205, 448 Kleinknecht, R„ 275, 456
Holton, G „ 549, 455 Klemke, E„ 195, 454
Homme, L., 156, 453 Kline, A., 535, 459
I lonig, VV„ 466 Klinger, E., 244, 454
Hoogduin, K „ 125, 455 Koch, S., 465
Hope, D., 452 Koelling, R., 151, 449
Horibuchi, S., 240, 241, 455 Koenig, H „ 409, 417, 454, 469
Horne, A., 447 Kondo, A., 149, 460
H ovland, C., 166, 455 Korchin, S., 155, 454
Howe, H., 445 Kosslyn, S., 254, 454
Howells, G., 46, 145, 440 Krasner, L., 155, 469
I loyt, S., 266, 445 Kroger, VV„ 15, 25, 157, 454
I luchinson, R „ 151, 440 Krop, H „ 156, 455
Huijing, R., 425, 453 Kuehlw ein, K., 445, 449
H ull, C , 121, 455 Kuiper, N'., 266, 465
Imber, S., 591, 446, 466 Kurlz, P., 549, 455
Ivald i Cdtud, A., 425, 455
Ivey, A., 416, 455 Ladouceur, R „ 156, 450, 455
Ivey, M., 416, 455 Lakoff, G., 596-99, 402, 403, 455
Lam oreaux, R., 131, 460
Jackson, J., 157, 444 Lande, S., 156, 471
Jacobs, A., 444 Landfield, A., 454
Jacobs, 11., 552, 558, 453 Langacker, R„ 195, 455
Jacobson, E„ 136, 157, 455 Lange, A., 36, 64, 102, 447
Jaeger, J., 558, 453 Lankton, C „ 158, 549, 423, 455
James, C., 23, 51, 55, 575, 459 Lankton, S., 158, 549, 423, 455
Jam ison, C , 56, 455, 465, 467 Last, J„ 290, 455
Jan is, I., 166, 455 La them, E., 454, 455
Jarem ko, M „ 156, 442 Lavigna, G „ 125, 455
Author Index

Lazarus, A., 156, 145, 165, 244, 249, 255, M aier, S., 75, 462
255, 425, 455, 456, 471 M andelkern, M., 536, 451
Lazarus, N., 255, 456 M an love, C., 425, 457
Lazarus, R., 285, 460 M anstead, A., 405, 449, 464
Leber, VV„ 591, 446 M arkam , S., 269, 449
Lega, L„ 577, 446 M arkus, H „ 405, 454
Legewic, H „ 158, 441 M arlatt, G „ 575, 440
Leitenberg, H., 125, 441 M arsella, A., 396, 405, 457
Leitner, L-, 454 M arshall, W „ 121, 457
Leonard, C „ 25, 156, 465 M a rtin ,)., 262, 423, 457
Leuner, H., 327, 425, 456 M artin, L„ 228, 457
Levine, D., 462 M aultsby, M „ 140, 248, 509, 457, 458
Levis, D., 121, 467 M aurice-Naville, D., 297, 460
Leviton, S., 550, 451 May, R., 109, 458
Levy, S., 339, 458 M ednick, S., 465
Liebowitz, M , 452 M eichenbaum , D., ix, 14, 25, 68, 141, 143,
Liese, B „ 351, 573, 575, 441, 456 163, 319, 459
Liotti, G , 51. 79, 80, 249, 285, 452 M elin, L„ 148, 451
Litt, M „ 25, 456 M eredith, R„ 156, 447
Lohr, )., 275, 456 M ill, J. S., 171, 458, 459, 460
Lo Lordo, V., 151, 448 M iller, F., 156, 447
Loudis, L., 341 M iller, N „ 148, 166, 459, 470
Low, A., 163, 456 M iller, P., 457
Ludgate, ]., 554, 471 M iller, W „ 575, 460
Lukoff, D „ 538, 456 M illiner, C , 149, 460
Lumeng, 575, 456 M ilton, F., 534, 460
Lumsden, D., 465 M innett, A., 36, 464
Lundh, L„ 58, 456 M oller, N., 375, 451
Lungwitz, H., 506, 456 M onat, A., 285, 460
Lunt, P., 162, 469 M onroe, S., 30, 467
Lynn, S., 158, 456 M ontangero, J., 297, 460
Lyotard, J., 405, 455 M oore, R., 125, 441
Moore, VV„ 162, 445
M e Bride, 575 M oreno, J., 514, 460
M cCarley, R., 211, 453 M orita, M., 149, 460
M cCurry, S., 423, 458 M orow itz, H., 96, 460
M cEvoy, J., 559, 458 Mosak, H „ 290, 297, 460
M cG inn, L., 84, 169, 174, 216, 255, 289, Moseley, S., 102, 447
510, 458 M owrer, O., 131, 460
M cG lashan T , 559, 458 M ulloy, J., 36, 443
M e Guigan, F., 465 M unitz, M., 193, 460
M ach, E„ 228, 456 M unson, C , 300, 460
M clnem ey, J., 72, 551, 447 M urphy, L„ 169, 575, 460
M ac Kewn, J., 514, 456
M cLaughlin, K., 58, 456 Nagel, E „ 195, 460
M acLeod, C., 58, 456 Navas, )., 23, 31, 458
M e M ahon, 575, 440 Neenan, M „ 64, 447
M acm illan, F, 559, 446 Neider, C., 469
M e M u llin , R., ix, 15, 14, 19, 25, 51, 55, 55, Neimeyer, R., x, 56, 169, 460
70, 79, 87, 125, 155, 156,187, 199, 216, Neugroschel, 1., 423, 460
249, 527, 555, 559, 558, 559-61, 565, 564- Neukrug, E., 262, 460
70, 575, 584, 396, 410, 444, 458, 459 Nevis, F„ 314, 460
M e M u llin , R. S., 66, 458 N ew hall, S., 228, 461
M e M u llin , T. E., 454-56 Newm an, C., 351, 441
M cN ally, R., 58, 156, 459, 471 Newm an, M., 34, 36, 460
M aher, B., 533, 456 Nielsen, S., 409, 461
M ahoney, M., x, xi, 12, 145, 156, 165, 169, Nisbett, R., 163, 461
216, 309, 319, 456, 457, 460 Nordstrom, G., 338, 462
 A u t h o r I n d ex

Novaco, R., 53, 444 Reed, A., 423, 463

Novick, L., 60, 444 Reed, D„ 338, 467
Nuechterlein, K „ 338, 456, 461 Rees, S., 100, 463
Reese, L., 46, 145, 440
Oberlander, M „ 385, 450 Reich, W., 417/463
Occam, 431 Reinecke, M., 87, 300, 449, 463
O 'Donohue, W., 125, 461 Reivich, K., 50, 466
Okpaku, S., 416, 461 Rescorla, R „ 119, 121, 275, 465, 471
O levitch, B „ 534, 461 Reyna, L., 156, 471
Olson, H „ 290, 298, 461 Reynolds, D„ 149, 465
Olson, M „ 447 Reynolds, E „ 125, 441
Olson, S., 125, 468 Rhue , )., 158, 463
Oltm anns, T., 456 Richards, C., 140, 464
Orne, M., 158, 461 Richardson, A., 143, 255, 509, 463
O rtlip, P., 339, 458 Richardson, C , 358, 467
Osl, L., 58, 156, 456, 461 Richardson, F„ 145, 468
Ozaki, B„ 349, 445 Richie, B., 131, 463
Rizley, R „ 275, 465
Palermo, D „ 43, 470 Robin, P., 454
Palmer, S., 64, 447 Roe, P., 409, 469
Paris, C „ 100, 461 Rogers, C. R„ 51, 159, 584, 463
Parloff, M ., 391, 446, Rogers, T., 266, 463
Paskewitz, D., 158, 461 Rokeach, M „ 266, 465, 464
Patwa, V., 554, 460 Roll nick. S., 575, 460
Pavlov, I„ 275, 461 Ronall, R „ 514, 448
Pedersen, P., 416, 461 Rosen, H., 445, 448, 449
Peris, F„ 314, 461 Rosenbluh, E., 550, 464
Perris, C , 538, 461, 462 Rosenstiel, A., 156, 465
Perris, H., 558, 461 Rosenthal, H „ 156, 442, 444, 445, 447, 450,
Petersen, C., 75, 462 452, 455, 460, 468, 470
Petry, 11., 85, 442 Ross, L „ 165, 461
Petty, R „ 166, 266, 462 Rossi, E „ 84, 158, 549, 448, 464
Piaget, }., 296, 462 Roth, L„ 559, 458
Pi Ikon is, P., 591, 446, 466 Rubin, D., 470
Plot kin, VV„ 158, 462 Rudolph, U., 60, 464
Plutchik, R „ 96, 455, 462 Rumor, V., 241, 464
Pohorecky, L„ 148, 470 Rush, A., 58, 441
Pomerantz, J., 254, 454 Russell, B „ 193, 451, 458, 464
Pope, K., 245, 255, 423, 467 Russell, J., 405, 449, 464
Popper, K„ 195, 427, 462 Ryan, E „ 429
Porter, P., 227, 462 Ryan, M „ 158, 549, 464
Powaga, W., 423, 462 Rygh, J., 84, 174, 510, 471
Premack, D„ 155, 266, 462 Ryle, G., 195, 455, 454, 458, 464
Prentice, D „ 266, 440
Preston, J., 409, 470 Sachs, L„ 444
Pretzer, )., 449 Safran, J., 450
Progoff, I., 523, 462 Safren, A., 45, 464
Sagan, C „ 205, 549, 464
Q iu, R., 417, 462 Salkovskis, P., 441, 456, 464, 468, 470
Quine, W „ 195, 426, 431, 458, 462 Salter, A., 156, 471
Sam ford, J., 555, 459
Rabhn, J., 155, 462 Sam pson , )., 56, 444
Rachlin, II., 151, 452 Sandry, M , 34, 464
Rachm an, J„ 174, 591, 462 Sanislow 111, C., 333, 444
Rachm an, S., 591, 440, 462 San I rock , )., 56, 464
Randi, J., 205, 340, 549, 463 Sarason, I., 459
Ravizza, R„ 193, 465 Sargant, W .r 262, 464
Ray, VV„ 193, 463 Sato, K„ 269, 449
Author Index

Saunders, J., 351, 375, 444 Snyder, K., 558, 456

Schaap, C., 125, 455 Sobel, G., 454
Schachter, S., 96, 115, 465 Sober-Ain, L., 174, 467
Schauss, S., 115, 465 Soblem an, S., 156, 442
Scherer, K„ 405, 465 Sokolov, E., 148, 467
Schneier, F., 452 Solom on, R., 151, 467, 469
Schotte, D„ 136, 471 Sorrell, S., 56, 466
Schuckit, M ., 375, 465 Sotsky, S., 391, 446, 466
Schulsinger, F, 375, 451 Spangler, D., 30, 467
Schunk, D. H., 46, 143, 441 Spaulding, VV„ 358, 467, 468
Schwartz, B„ 119, 121, 465 Speechley, K „ 558, 430
Schwartz, G., 158, 465 Spielberger, C., 43, 465, 467
Schwartz, M., 158, 465 Sprague de Camp, L„ 205, 467
Schwarzer, R., 46, 465 Spring, B„ 558, 471
Schwebel, A., 300, 465 Stableford, B „ 423, 467
Scogin, F., 56, 453, 465, 467 Stampfl, T., 121, 467
Scott, D., 23, 156, 465 Steam, J., 158, 467
Scurfield, R„ 596, 403, 457 Stein, M „ 140, 467
Seifert, R„ 156, 158, 444 Steiner, S., 158, 468
Seligm an, M ., 50, 72-75, 131, 356, 337, 443, Sternbach, R., 23, 468
462, 465, 466 Storzbach, D., 338, 467
Selm i, P., 56, 466 Strauss, J., 336, 451
Sem in, G., 403, 466 Stroebe, W., 466
Sensenig, J., 169, 445 Strosahl, K „ 151, 194, 539, 452
Shaban, ]., 169, 443 Stubbs, D„ 275, 468
Shaffer, ]., 245, 425, 466 Stuve, P., 538, 468
Shapiro, D., 36, 451 Suinn, R., 143, 468
Shapiro, F„ 148, 275, 466 Sullivan, M , 538, 467
Shaw, B., 58, 441 Summer, W . G., 396, 468
Shea, T., x, 391, 446, 466 Sutcliffe, J., 136, 157, 468
Shear, K „ 58, 444 Sutker, P., 444, 448
Sheets-Johnstone, M „ 450 Symons, C., 58, 262, 468
Sheikh, A., 244, 245, 255, 425, 466 Szasz, T„ 153, 468
Shepherd, I., 514, 448
Shipley, R., 119, 442 Tafrate, R., 36, 64, 447
Shlien, J., 450 Taibbi, R„ 300, 468
Shorr, J., 262, 423, 454, 466 Tarrier, N „ 358, 442
Sichel, J., 102, 447 Taylor, C , 54, 461
Sidm an, M , 131, 466 Taylor, F S., 195, 203, 468
Sicgelm an, E., 423, 466 Taylor, M .f 403, 455
Sigvardsson, S., 375, 442, 444 Taylor, S., 174, 461, 468
Sim ek-M organ, L., 416, 453 Teasdale, J., 12, 145, 195, 468
Sim kins, L., 158, 466 Thase, M „ 30, 554, 467, 471
Sim on, J., 193, 466 Thoresen, C„ 145, 156, 309, 457
Sim on, K „ 84, 96, 449 Thorpe, G „ 125, 468
Sim ons, A., 30, 467 Tigner, A., 338, 455
Singer, A., 338, 444 Toiin, D., 275, 456
Singer, J., 96, 125, 143, 245, 255, 425, 460, Torrey, E „ 269, 468
465, 466, 467 Trabasso, T., 195, 469
Skagerlind, L„ 338, 462 Trachtenberg, M , 575, 442
Skinner, B. F, 155, 199, 275, 519, 467 Troeng, I.., 338, 462
Sm ith, G „ 128, 454 Trower, P., 558, 444
Sm ith, J. C., 136, 467, 469 Tuckey, J„ 469
Sm ith, M., 266, 467 Turk, F>., 14, 459
Sm ith, N., 36, 467 Turkat, 1., 25, 156, 469
Sm ith, R., 423, 467 Turkington, D „ 338, 454
Smokier, I., 289, 442 Turner, L., 151, 469
Snres, L., 169, 445 Twain, M., 207, 469
488 A u t h o r I n dex

Udolf, R., 157, 158, 469 W hiteley, J„ 102, 179, 447

U llian J., 426, 451, 438, 462 W hittal, M „ 45, 470
U llm ann, L., 155, 469 W icklund, R „ 115, 470
Urm son, J., 195, 469 W iers, R., 269, 449
W ilde, J., 248, 470
Van Der Dennen, J., 506, 469 W illiam s, J. M „ 57, 58, 245, 285, 470
Van Dusen, K., 465 W ilson, E., 506, 470
Van Gogh, V., 454-57 W ilson, 180, 195, 458, 470
Vaughan, F., 451 W ilson, K., 128, 151, 194, 539, 452, 470
Velten, E „ 102, 575, 447 W inokur, G., 575, 451
Ventura, J., 538, 456, 461 W olfe, J., 102, 447
Verrier, R., 156, 455 W olpe, J., 121, 156, 509, 470, 471
Vidam antas, R„ 575, 465 W orsick, D„ 241, 471
W ray, R „ 56, 444
W allenkam p , )., 405, 464 W right, F„ 96, 551, 459, 441
W alsh, R „ 451 W right, J., 554, 471
W arner, W „ 162, 469 W ynne, L., 151, 467
W atkins, H „ 174, 469
W atkins, J., 174, 591, 446, 466, 469 Yeager, R „ 72, 102, 551, 447
W atson, P., 195, 469 Yeats, W „ 423, 471
Weaver, A., 409, 454, 469, 470 Young, J., 84, 87, 174, 216, 255, 289, 510,
W edding, D., 549, 445 514, 425, 445, 458, 471
W ehrly, B „ 56, 416, 470 Yuker, H „ 227, 241, 442
Weiler, M „ 558, 467
Weim er, W „ 45, 470 Zaffuto, A., 158, 471
Weinberger, A., 84, 471 Zebb, B . )., 96, 140, 441
Weiss, J., 148, 470 Zeig, J., 450
W estling, B „ 156, 461 Zeitlin, S., 58, 444
Wever, E „ 228, 470 Zeleny, L., 514, 460
W hite, R „ 266, 467 Zim m er-Hart, C., 121, 471
W hitehead, A., 195, 470 Zubin, J., 558, 471
R ia n E . M e M u l l i n , P h .D ., is d ire c to r o f the
C o u n se lin g R esea rch In s titu te , a licen sed clinical
p sy ch o lo g ist a t the H aw aii S ta te H o sp ital, and on
th e clin ica l-a sso cia te facu lties at th e U n iv ersity o f
H aw aii and th e A m erican S ch o o l o f P rofession al
P sych ology. H e is th e au th o r o f e ig h t books, in ­
clu d in g (w ith T . G ile s ) C ogn itive-B ehavior Therapy:
A R estructuring Approach and (w ith B . C asey) Talk
Sense to Yourself: A G uide to Cognitive Restructuring
Therapy.

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 Advance Acclaim for the
New Handbook o f Cognitive Therapy Techniques
“An exceptionally comprehensive compilation o f the methods o f cognitive
behavior therapy. M uch more thoroughgoing than the first edition, including
many case histories. Q uite original and brilliant. I f anything im portant is miss­
ing, I could not find it.”
— Albert Ellis, P h .D .
President, Albert Ellis Institute, New York
Author, A Guide to R ational Living

“T h e first edition o f this book was the definitive text on treatm ent techniques;
the current volume is an enlarged, comprehensive update. R ich, image-laden
vocabulary describes the concepts o f attribution, explanatory style, self-instruc-
tion, expectations, story-telling, and the principle o f parsimony, am ong many
others. T h ere is a wonderful section on teaching cognitive therapy and another
on the impact o f culture on beliefs. T h is book will be referred to by every
enlightened practitioner o f the cognitive model. It is a feast with delicacies to
satisfy every cognitive taste.”
— Dean Schuyler, M .D .
Clinical Associate Professor o f Psychiatry
Medical University o f South Carolina
Author, A Practical G uide to Cognitive Therapy

“W hen the first edition o f this handbook was published in 1986 it served as a
major impetus for the growth o f cognitive behavior therapy (C B T ). It quickly
became a basic reference for therapists who needed a single resource for devel­
oping therapeutic strategies and treatm ent plans. T h e new edition far surpasses
the original work, offering broader coverage o f clinical disorders, extensive case
examples, and increased clinical sophistication in keeping with the increased
sophistication o f the field. T he practicing C B T clinician will find many useful
treatm ent ideas, therapists who are not C BT -trained will find treatm ent strate­
gies that can be integrated into their model, and the graduate instructor will
find value in its text potential.”

— Arthur Freem an, E d .D ., A BPP

Chair, Departm ent o f Psychology
Philadelphia C ollege o f O steopathic M edicine

ISBN 0-393-70313-4
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