Milton Spett, Ph.D.
The Two Critical Components of All Psychotherapies:
Experience the Emotion – Change the Cognition
In his Sept. 19 NJ-ACT workshop on Unified Treatment, Milton Spett discussed his theory that there are two critical components that underlie the effectiveness of all psychotherapies. This article is an adaptation of his presentation.
A schema is a self-perpetuating system of interacting cognitions, emotions, behaviors and perceptions of the self and the world. For example, a low self-esteem schema would include the belief one is a failure, feelings of inadequacy or guilt, ineffective behavior, the perception one’s behavior is ineffective, and the perception that others disapprove of oneself. There is a tendency toward consistency among all the components of a schema. So if a low self-esteem patient initially perceives that he behaved effectively, his feelings of inadequacy would tend to convert that perception into a perception that the behavior was ineffective or even humiliating.
Schemas are situation specific, so a patient may experience a self-confidence schema in some situations, and an inadequacy schema in other situations. When a schema is not being experienced it is dormant, but it still exists and will be activated under stress or if certain events occur.
Schemas are most accurately viewed as propensities to think, feel, behave, and perceive in certain ways. Our goal as therapists is not just to help patients think, feel, behave, and perceive appropriately for a day or a month or until the next stressor comes along. Our goal is rather to weaken or eliminate patients’ dysfunctional schemas, so that regardless of the situation or the stressor, our patients will think, feel, behave, and perceive functionally.
Patients often report that they had a good week because they were successful, or they handled situations effectively, or they received positive feedback, and they felt good about themselves. But I do not consider this a good week. A good week is when patients make mistakes, fail, or are criticized, but still feel good about themselves. A good week is when situations occurred that previously evoked patients dysfunctional schemas, but no longer do so because those schemas have been weakened or eliminated
Schema ChangeThe best opportunity for weakening a dysfunctional schema is when the schema is activated, when the patient is experiencing an inappropriate negative emotion. At these times patients should attempt to think and behave functionally. Here are three more schema change techniques:
1. Experiencing their dysfunctional emotions sometimes leads patients to spontaneous schema change.
2. Gentle questioning can sometimes nudge patients toward schema change.
3. Disputing our patients’ dysfunctional cognitions is the most aggressive approach to schema change.
The technique should be geared to the patient’s ability to tolerate directive interventions.
Schema change requires repetition. Patients slightly weaken their dysfunctional schemas each time they think and behave functionally while experiencing a dysfunctional emotion. Patients may not notice much change the first time they think and act functionally while experiencing a dysfunctional emotion, but if they do this repeatedly, they will recognize that their dysfunctional emotions have weakened significantly. Eventually, thinking, feeling, behaving and perceiving functionally will become just as automatic as thinking, feeling, behaving and perceiving dysfunctionally used to be.
Experience the Emotion – Change the CognitionBefore a schema can be weakened, the patient must not only experience the emotion, but also have a clear understanding of the emotion and the associated cognitive components of the schema. Repeatedly discussing and exploring the precipitating event and the associated cognitions and emotions can help patients to clarify and understand confused or jumbled emotional reactions.
Expressing an emotion can enable a patient to fully experience that emotion, but it is experiencing and understanding the emotion, not expressing the emotion, that enables therapeutic schema change. Thinking or writing about an upsetting experience can enable a patient to experience, clarify, and understand the emotion, and eventually change the cognition.
Patients’ natural impulse is to reduce the intensity of their negative emotions, often by keeping busy in order to distract themselves from these emotions. It is often pragmatic to suppress negative emotions in order to accomplish some necessary task. But if a patient keeps constantly busy and never experiences his or her negative emotions, that patient’s propensity to experience negative emotions will never change. The patients’ dysfunctional schemas will remain dormant, but they will remain, and keep the patient at risk for developing psychological symptoms.
Once an inappropriate negative emotion is experienced, clarified, and understood, our job is to help patients identify and change the associated dysfunctional cognitions. Cognitive change is the driving force behind schema change. Behavioral change without cognitive change can temporarily alter patients’ thoughts, feelings and perceptions, but will not weaken dysfunctional schemas. To effect schema change, behavioral change must lead to cognitive change.
The research on situational anxiety disorders consistently finds that experiencing the emotion (anxiety) leads to greater patient improvement. The more anxiety experienced, the more active the dysfunctional schema and the more opportunity for weakening that schema.
This is why in treating anxiety disorders we focus on exposure, exposing patients to the situations that evoke their dysfunctional schemas, and then changing their cognitions – usually their cognitions regarding the danger of their anxiety symptoms and the situations that evoke them.
The most important cause of panic and phobias is the fear of panic and phobic symptoms. We encourage these patients to expose themselves to situations that evoke their symptoms and to remain in those situations until their symptoms diminish significantly. We also advise patients to passively wait for the symptoms to diminish, doing nothing to reduce their symptoms. This intervention changes patients’ cognitions that their symptoms and the situations that evoke their symptoms are dangerous. Exposure exercises cause panic and phobia patients to experience their dysfunctional emotion (anxiety) and change their dysfunctional cognitions about this emotion.
The first step in PTSD treatment is also to expose patients, usually through imagination, to the traumatic situation which evokes their dysfunctional emotion. There are two approaches to the second step, changing the cognition. Edna Foa advocates waiting passively for spontaneous change in the patients’ dysfunctional cognitions regarding danger, fear, and/or guilt. Patty Resick suggests active efforts to change these dysfunctional cognitions.
In treating OCD, the key dysfunctional cognition is the patient’s negative evaluation of the obsessive thought. By exposing patients to their obsessive thoughts, patients gradually change their negative cognitions about these thoughts. Again, the key interventions are having patients experience their dysfunctional emotion (anxiety over a thought) and change their dysfunctional cognitions.
We also ask OCD patients to refrain from performing their compulsions. These compulsions are assumed to serve the function of reducing the anxiety provoked by the obsessive thought. Compulsive behaviors are counterproductive because they impede experiencing the emotion – anxiety. In addition, any behavior that attempts to reduce anxiety strengthens the dysfunctional cognition that the anxiety is intolerable.
Any form of relaxation, meditation, or breathing exercise can be counterproductive by impeding experiencing the emotion and by strengthening the dysfunctional cognition that the anxiety is intolerable. Relaxation should not be used with situational anxiety disorders, in part because unless the anxiety is very weak, they don’t work. Instead, we should encourage patients to experience their anxiety symptoms and change their dysfunctional cognitions about those symptoms.
On the positive side, mastering relaxation exercises can change patients’ dysfunctional cognitions that they have no control over their symptoms and their lives. For this reason, relaxation is sometimes indicated in treating generalized anxiety.
Depression
There is no research on the question of whether treatment of depression is more effective when the patient is experiencing the depression. But research has found that when depressed patients are not experiencing their depression, that is, when their depressive schema is dormant, depressed patients’ thoughts, feelings, behaviors, and perceptions are indistinguishable from those of non-depressed individuals. So it seems reasonable to assume that when a patient is not experiencing depressed thoughts and feelings, that patient’s depressive schema is dormant and more difficult to access and weaken.
The depressive schemas of patients who experience chronic depression are almost always active and susceptible to change through cognitive and behavioral interventions. But with patients who experience episodic depression, it is helpful to ask these patients to be aware of when they experience depressive emotions, and pay attention to these emotions rather than keeping busy to distract themselves from their depression. This technique enables depressed patients to clarify their depressive cognitions and emotions. When they experience rather than avoid their depressive emotion, most patients report that the depressive episode passes more quickly. In addition, they become less afraid of their depressive symptoms and better able to clarify and change the dysfunctional cognitions that are part of their depressive schemas.
These patients’ depressive schemas are active and susceptible to therapeutic change only when the patients are experiencing their depressed emotions. I have treated several depressed patients whose progress was directly correlated with their ability to experience their depression, both in sessions and between sessions. Doris, a depressed patient I have been treating for twelve years made her greatest progress in this year when she was finally able to remember and reexperience the intense emotion associated with certain childhood events.
Doris called me one morning last month and asked if she could see me that day. I asked if she could wait for her regular appointment in two days. She said “no,” so I saw her that day. In our session Doris talked about the depressive memories, emotions, and cognitions she was experiencing at that moment, emotions and cognitions she had suppressed for many years. At the end of the session she said the session had been very helpful, and she added that if she had waited until her regular session, she would have re-suppressed the memories, emotions and cognitions she had experienced and explored.
Medication can suppress psychological symptoms temporarily, but after a course of medication, patients are just as likely to experience their psychological problems as they were before taking the medication. The benefits of medication are temporary, but the benefits of psychotherapy endure, and sometimes increase, after treatment is terminated. So if our goal is to cure our patients rather than provide palliation, psychotropic medication should be evaluated in terms of its effect on psychological treatment.
Medication can sometimes provide a quick improvement in symptoms, possibly preventing a serious, real-life loss, such as the loss of a job or the dissolution of a marriage. But medication can also cause a patient’s dysfunctional schemas to become dormant and inaccessible to psychotherapy. Two follow-up studies of anxiety disorders, one led by David Barlow and one led by Michael Otto, have found that CBT alone is more effective than CBT plus medication.
Avoiding negative emotions makes patients comfortable in the short run, but prevents them from overcoming their psychological problems in the long run. Experiencing negative emotions makes patients uncomfortable in the short run, but presents the opportunity for curing their psychological problems in the long run.
Wilma was a depressed patient who entered psychotherapy while taking an anti-depressant. We discussed certain events which had done serious damage to her self-esteem, and which evoked some dysfunctional emotions and cognitions. She was improved, but she still experienced some depression. Then she weaned herself off her medication. Now we explored these same experiences again and she reported substantially more depressed emotion. I made the same interventions I had made previously, and after a few months Wilma was completely over her depression. She called sixteen months after termination about another matter and reported that she continued to enjoy life with absolutely no periods of depression. Her medication had initially been suppressing her depressive schema, making it partially dormant and inaccessible to therapeutic intervention.
Psychodynamic therapists emphasize the first core component of effective psychotherapy -- helping patients to experience their dysfunctional emotions and activate their dysfunctional schemas. When psychodynamic therapists encourage their patients to explore early experiences, the therapists are not attempting to change those early experiences. Psychodynamic therapists are trying to change the current “unconscious thoughts and feelings” which may have been caused by those early experiences.
But what are unconscious thoughts and feelings? What is a feeling that you don’t feel and a thought you don’t think? Unconscious thoughts and feelings must be propensities to experience certain emotions and cognitions that are not currently being experienced. In other words, unconscious thoughts and feelings must be schemas, probably dysfunctional schemas. Dysfunctional schemas can be activated when patients explore early negative experiences. Dysfunctional schemas can also be activated when patients explore recent or current negative events.
Unfortunately, psychodynamic therapy has no formal mechanism for changing cognitions, the second core component of effective therapy. Sometimes patients in psychodynamic therapy change their cognitions spontaneously or in response to gentle questioning from the therapist. I once gave a workshop with a psychodynamic therapist in which we each explained how we would treat specific cases. The essence of the differences between our approaches is that I would say to patients, “You should do X,” while the dynamic therapist would say “I wonder why you don’t do X?” This question clearly implies that the patient should do X, and I would argue that this gentle direction is how psychodynamic therapists sometimes change their patients’ dysfunctional cognitions and schemas.
Cognitive-behavioral therapists have many effective techniques for changing dysfunctional cognitions and schemas. But, CBT therapists tend to overlook the importance of helping patients to experience their negative emotions, the surest sign that patients’ dysfunctional schemas have been activated and are available for therapeutic change.
ConclusionThe principles “Experience the emotion – change the cognition,” constitute the most powerful components of all effective psychotherapies. This concept applies not just to depression and anxiety disorders, but to almost all psychological problems. Treatment consists of the following steps:
1. Confront the situation that evokes the psychological problem, either in vivo or by talking, thinking, or writing about it.
2. Experience the inappropriate emotions.
3. Clarify and understand these emotions.
4. Do not act in accordance with these emotions.
5. Identify and change the associated dysfunctional cognitions.
6. Each time this process is repeated, the dysfunctional schema weakens.
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