By Aaron T. Beck, MD, and Molly R. Finkel, MSEd
In everyday life, many transient cognitions (automatic thoughts) serve the purpose of alerting the individual to a problem or new stimuli. After these cognitions are activated, individuals then experience a variety of affects, which also serve an alerting function, and tend to be more compelling compared to cognitions.
When individuals are in a psychopathological state, their cognitions and affects also provide an alert. However, the activated psychopathological mode contains biased cognitions (meanings made of stimuli) based on stored cognitive schemas and affects in an exaggerated/prolonged form. The form of exaggerations may be cognitive distortions (such as overgeneralization, selective abstraction and catastrophizing, amongst others); intense affective reactions (the strength of which is unwarranted given the circumstance); and a prolongation of intense cognitive bias and affect across time. Psychopathological modes tend to remain activated for a prolonged period and/or may have extreme cognitive content or meaning.
For example, the dysthymic/aversive disorders, namely depression, anxiety and violence, represent maladaptive exaggerations of everyday aversive cognitive and affective reactions of anxiety, sadness and anger.
- In anxiety, the cognitive content is provided by the cognitive schemas which may have the meaning of threat. For example, in social anxiety the cognition might be “I am vulnerable in social situations and will be rejected if I stick my neck out.” The individual responds with anxiety and frequently copes by using avoidance techniques to withdraw from the situation (flight reaction).
- In depression, the preexisting cognitive schema provide a meaning attached to the situation that pertains to loss, disappointment, self-criticism, etc., within oneself. The person overgeneralizes and makes a value judgment about the self, for example, “I am stupid, worthless, no good,” etc. Therefore, there is a self-attribution of loss and associated affects of sadness and hopelessness.
- In disorders that contain violence, anger and aggression, the individual attaches the meaning of loss or the meaning of violation (of their values), but attributes the cause of the loss or violation to another individual who has criticized, threatened, disrespected, or let the individual down. The individual responds with anger and a sense of devaluation, which may be expressed with a fight reaction (or the individual may not express the anger externally).
There are two contrasting approaches to treatment. In one approach, the therapist uses logic and reasoning to correct the aversive evaluations of the self and the task. This could include reviewing past experiences which contradict the aversive interpretations (examining the evidence) or using cognitive reframing to consider a stimulus situation from a different, more adaptive perspective. This is the standard cognitive therapy approach. The Recovery-Oriented Cognitive Therapy (CT-R) approach operates at a higher level and instead of emphasizing logic and reason, employs the appetitive aspect of the personality.
When the modes are in the aversive state (depression, anxiety, or aggression), the therapeutic strategy is to diffuse these modes. This is done through the standard methods of applying logic, looking for alternative explanations, etc. While this emphasis is on diffusing the state of the aversive mode, the therapist also has the option of activating the appetitive mode. This mode has to do with safety, self-confidence, sociophilia, optimism, etc., and taps into the reward system, generating optimism and pleasant affect. The therapist must, of course, draw conclusions about the broad characteristics that the actions show in the activation of the appetitive mode. The CT-R approach emphasizes the difference between the contradiction of aversive modes, often done through talking, and in activating the appetitive mode through action. The appetitive mode involves a rewarding affect in addition to changing the cognitive structuring. Thus, the two different modes act as a seesaw: when the appetitive aversive is activated, the aversive is deactivated.
The therapist attempts to activate previous positive evaluations of the self through collaboratively designing positive experiences for the individual to engage in, which provide opportunities for the individual to achieve their aspirations. This learning (or re-learning) is experiential in that it relies on action as a therapeutic modality. In order to be effective, however, it is important for the therapist and patient to draw conclusions about the meaning of successful experiences and the individual’s strengths, assets, opportunities and capabilities.