How to Change Dysfunctional Cognitions

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A different version of this article appears in Child and Family Behavior Therapy

Dysfunctional Cognitions: Should We

Dispute, Question, Analyze, Accept, Validate, Ignore,

Or Be Mindful of Them?

By Milton Spett

With the exception of a few radical behaviorists, all cognitive-behaviorists agree that dysfunctional cognitions are the core component of psychological disorders. And virtually all cognitive-behaviorists agree that changing dysfunctional cognitions is the core component of effective psychotherapy. But there is widespread disagreement within CBT about how to change our patients’ dysfunctional cognitions.

Dispute dysfunctional cognitions -- cognitive therapies

In the 1960s Albert Ellis proposed the then-revolutionary concept that psychological problems are caused by dysfunctional cognitions. (Ellis called them “irrational beliefs.”) According to Ellis, the most important therapeutic intervention was “disputation,” teaching patients to dispute their dysfunctional cognitions and replace them with functional cognitions. (Ellis called the latter “rational beliefs.”)

In the 1970s Aaron Beck argued that psychological problems are caused by both dysfunctional cognitions and faulty information processing. Beck viewed patients as bad scientists, using faulty information processing to develop and maintain erroneous theories (dysfunctional cognitions). Beck asserted that therapists should teach patients to become good, logical scientists. Beck used logical arguments (disputation) and behavioral experiments to change patients’ dysfunctional cognitions. Within a few years virtually all cognitive and behavioral therapists agreed with Beck that the essence of psychotherapy is changing dysfunctional cognitions with logical arguments and behavioral experiments.

And there the matter rested for a quarter century.

____________

Third wave therapists maintain that

cognitive interventions are unnecessary.

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But then as the third millennium approached, a new wave of cognitive-behavioral therapies began to form. This movement has been called the “third wave” by Stephen Hayes. (Behavior therapy was the first wave and cognitive therapy was the second.) The therapies that formed this new, third wave agreed that dysfunctional cognitions should not be disputed. But the various third wave therapies have presented a wide variety of alternatives to disputing dysfunctional cognitions.

Validate dysfunctional cognitions -- dialectical behavior therapy (DBT)

The first third wave therapy actually has one leg in the second wave and one leg in the third. Marsha Linehan’s DBT recommends both validating and disputing dysfunctional cognitions, but she places far greater emphasis on validation. In DBT, “validating” means accepting as understandable or reasonable under the circumstances. For example, it is understandable that patients who have experienced traumatic events would develop dysfunctional cognitions about their safety.

The apparent conflict between validating and changing dysfunctional cognitions, emotions, and behavior is the core dialectic in DBT. According to Linehan, therapists must balance validation and change throughout treatment, in every session, and in every interaction with patients. Linehan points out that every intervention aimed at change can be experienced by the patient as invalidating.

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The third wave focuses on

behavioral interventions.

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Linehan describes six types of validation:

1. Listening to, observing, and trying to understand what patients are saying, feeling, and doing.

2. Accurately reflecting back to patients the therapist’s understanding of patients’ expressed feelings, thoughts, assumptions, and behavior.

3. Articulating patients’ unexpressed thoughts, feelings, wishes, etc.

4. Justifying patients’ thoughts, feelings, and behavior in terms of past experiences or biological dysfunctions.

5. Justifying patients’ thoughts, feelings, and behavior in terms of their current psychological state.

6. Articulating the patient’s abilities and accomplishments; seeing patients as more than their psychological problems; viewing patients as individuals who are entitled to status and respect.

7. Expressing optimism that patients can overcome their problems, grow, and achieve more of what they want in life.

In Linehan’s view, validation creates a strong therapeutic relationship, enabling the therapist to use mostly behavioral techniques plus some cognitive and paradoxical techniques to change dysfunctional cognitions.

Question dysfunctional cognitions -- many therapies

Many cognitive-behavioral therapists recommend “Socratic questioning” to change dysfunctional cognitions. Socratic questioning means asking questions which will gently lead patients to change their dysfunctional cognitions without directly disputing those cognitions. Some of the therapists who recommend this approach are David Barlow in his Unified Protocol for Emotional Disorders; Patricia Resick in her Cognitive Processing Therapy for PTSD; David A. Clark’s CBT for obsessions; and Craske & Barlow’s Panic Control Treatment.

Resick et al. (In Barlow, ed. Clinical Handbook of Psychological Disorders, 2008, p. 97) give an example of Socratic questioning. The patient had developed PTSD after shooting at a car that ignored warnings to slow down as it approached a checkpoint in Iraq. The car contained an innocent family, and several family members died. First the patient wrote a complete description of the events, his behavior, and his feelings. Next the therapist encouraged the patient to read his description and fully experience his emotions.

Finally the Socratic questioning:

Therapist: If a person shot someone but didn’t intend to do that, what would we call that?

Patient: An accident, I guess.

Therapist: That’s right, in fact, what would you call shooting a person when you are trying to protect something or someone?

Patient: Self-defense.

Note that by asking questions, the therapist is clearly suggesting that the patient change his view of himself and his actions.

Accept dysfunctional cognitions -- acceptance and commitment therapy

Acceptance and commitment therapy (ACT) asserts that the avoidance of cognitions and emotions is a key cause of psychopathology. A critical component of ACT is asking patients to accept and experience their cognitions and emotions, without judging or trying to change them. ACT uses mindfulness and imagery exercises to help patients experience rather than avoid cognitions, emotions, and memories. ACT also encourages patients to pursue their valued goals in spite of any conflicting cognitions and emotions.

ACT asserts that cognitive restructuring (disputation) adds nothing to behavioral techniques. In fact cognitive restructuring violates ACT’s basic assumption that dysfunctional cognitions should be accepted rather than judged or disputed. ACT asserts that the more patients attempt to suppress their dysfunctional cognitions and emotions, the more intense those cognitions and emotions become.

ACT also asserts that when patients stop trying to suppress dysfunctional cognitions and emotions, those cognitions and emotions will diminish in intensity, making it easier for patients to pursue those life goals they value most. But note that asking patients to pursue the life goals they value most, in spite of conflicting cognitions, clearly implies that those cognitions are dysfunctional or at least irrelevant.

Notice dysfunctional cognitions -- mindfulness-based cognitive therapy (MBCT)

In MBCT dysfunctional cognitions are simply “noticed.” Instead of focusing on the content of negative cognitions, MBCT teaches patients to view these cognitions as events that pass through the mind, and to non-judgmentally observe this process as it occurs. “Decentering,” refers to two basic concepts in MBCT:

1. “My thoughts are not facts” and

2. “My thoughts are not the center of my being.”

When patients become aware of a dysfunctional cognition (or emotion), MBCT instructs patients to:

1. Observe your cognition without evaluating, planning, or acting on it.

2. Focus on your breathing for a minute or two.

3. Expand your attention to your whole body for a minute or two.

4. Notice how the cognition (or emotion) affects your bodily sensations.

MBCT does not directly dispute dysfunctional cognitions, but by instructing patients not to act on these cognitions, and not to assume that these cognitions are accurate, MBCT certainly implies that dysfunctional cognitions are inaccurate.

Ignore dysfunctional cognitions I -- behavioral activation

Behavioral activation (BA) focuses on the consequences of behavior. Behavior that helps patients achieve their goals is encouraged, while behavior that prevents patients from achieving their goals is discouraged. For example, suppose a patient wants friends, but believes that everyone hates him. A cognitive therapist would try to convince the patient that this belief is incorrect. But a BA therapist would ask the patient, “What are the consequences of this belief?”

The consequences of believing everyone hates you are avoiding people and not having friends. But one of the patient’s goals is to have friends, and patients recognize that avoiding people prevents them from having friends. So the BA therapist encourages patients to interact with people in order to achieve their goal of having friends.

BA theory also asserts that patients must keep struggling with their old avoidance habits until they are replaced by new active habits. BA therapists do not dispute dysfunctional cognitions, but by asking patients to disregard their dysfunctional cognitions, BA conveys the impression that these cognitions are unhelpful or incorrect.

Ignore dysfunctional cognitions II -- exposure & ritual prevention

Edna Foa recommends exposure and ritual prevention (ERP, sometimes called “exposure and response prevention”) for several anxiety disorders, most notably OCD. Foa believes that that the core problem in OCD is dysfunctional cognitions about danger. But her treatment pretty much ignores these cognitions and focuses on behavioral interventions -- exposure and ritual prevention.

OCD theory asserts that obsessions create anxiety, and compulsions are rituals designed to reduce this anxiety. Exposure means experiencing the obsession or experiencing the situation that provokes the obsession and the urge to perform a ritual. Ritual prevention means not performing that ritual. Foa asserts that frequent and prolonged ERP will change the OCD patient’s dysfunctional cognitions regarding danger.

For example, if the obsession is the thought “What if I have AIDS?”, the ritual might be getting tested for AIDS. When the test results are negative, the patient feels better for a while, but after a few days or weeks the patient will begin to wonder “What if the lab made a mistake? I better get tested again to be sure.“ And this cycle of obsession, ritual, and temporary anxiety reduction will continue on and on and on. According to Foa, the best way to change the patient's dysfunctional cognition that he may have AIDS is to experience the obsessive fear, and just wait for the fear to run its course without performing any compensatory behavior designed to reduce the fear.

Foa’s theory is that exposure works because it provides evidence which disconfirms the patient’s dysfunctional cognitions about danger. Foa does not recommend that therapists dispute, question, validate, accept, or use mindfulness techniques to change patients’ dysfunctional cognitions. But telling a patient who believes he has AIDS to refrain from getting tested clearly suggests that this patient does not have AIDS.

Analyze dysfunctional cognitions: Psychoanalytic therapy

The essence of psychoanalytic therapy is analysis, helping patients identify the putative underlying causes of their dysfunctional cognitions, emotions, and behavior. These underlying causes can be either in the patient’s childhood, or in their current psychological structure. Analytic theory asserts that an empathic therapeutic relationship will help patients to experience and understand their inner lives (make their unconscious conscious) and then dysfunctional cognitions, emotions, and behavior will remit.

In a workshop I once gave with a psychoanalytic therapist, I described how I would treat several hypothetical cases, and the psychoanalytic therapist described how she would treat those same cases. The basic difference between us was that I would say to patients “You should go home and do X,” while she would say “I wonder why you don’t go home and do X.”

Note that analysts do not ask their patients to analyze every cognition, emotion, or behavior. Analysts only ask patients to analyze those cognitions, emotions and behaviors that the analyst judges to be dysfunctional. Telling patients you wonder why they don’t do X gently implies that they should do X, and that their cognitions justifying their not doing X are dysfunctional.

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-- Let’s go to the research ---

Third wave theorists like Steven Hayes argue that therapists do not need to dispute dysfunctional cognitions. These theorists assert that cognitive interventions plus behavioral interventions are no better than behavioral interventions alone. And since behavior therapy is simpler and easier to learn than cognitive-behavior therapy, we should just do behavior therapy.

In fact, several studies have found that behavior therapy is just as effective as cognitive-behavior therapy. But keep in mind that these findings pertain only to the very short-term treatment in most research studies. Research on long-term therapy might find that that cognitive-behavior therapy is more effective than behavior therapy, or is more effective for certain patients.

But even if it isn’t superior, cognitive-behavior therapy is no less effective than behavior therapy according to the limited research available. So it seems to me that the safest course is to try both cognitive and behavioral techniques, and see which are most effective with each individual patient at any given point in treatment.

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Do we need to dispute dysfunctional cognitions?

I have argued that telling patients that their cognitions are not necessarily accurate, and asking patients to question their cognitions are really gentle, indirect ways of suggesting to patients that their cognitions are dysfunctional. In addition, telling patients to pursue their valued goals in spite of their conflicting cognitions, and telling patients to be mindful of their cognitions without necessarily acting on them, are also gentle, indirect ways of telling patients that their cognitions are dysfunctional. Similarly, doing behavioral activation or ERP while ignoring conflicting cognitions, or both validating and disputing cognitions, or even asking patients to analyze certain cognitions but not others, are all techniques which clearly, but gently imply that the cognitions are dysfunctional.

So the question should not be “Do we need to dispute dysfunctional cognitions?” The question should be “How directly or indirectly, how gently or forcefully, should we dispute each dysfunctional cognition with each patient at each point in treatment?”

This question brings to mind “reactance,” a social psychological concept with a great deal of empirical support. Reactance refers to the finding that a gentle, indirect argument against a belief sometimes (but not always) accomplishes more attitude change than a direct challenge to that belief. We therapists can use this social psychological finding to guide our choice of cognitive interventions.

Sometimes disputation can quickly change a dysfunctional cognition. But in the following situations, I believe behavioral techniques or gentle, indirect cognitive techniques would be more effective:

1. With oppositional patients, all cognitions should probably be addressed behaviorally or with gentle, cognitive interventions rather than direct disputation.

2. Behavioral or gentle third wave techniques should be used when a dysfunctional cognition is deeply entrenched, firmly believed by the patient. For example, patients suffering from major depression, with severe feelings of low self-esteem, should usually be treated with behavioral or third wave techniques rather than disputation, at least until their depression diminishes. Dimidjian et al. (J. Consulting & Clinical Psychology, August, 2006) found that behavior therapy was more effective than CBT for severely depressed patients (Hamilton Rating Scale for Depression >19).

This point suggests that some of a patient’s dysfunctional cognitions should be disputed, while other cognitions of the same patient should be treated with behavioral or gentle, indirect cognitive techniques.

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-- Case example --

Priscilla was referred to me by her psychoanalyst-father for depression. He thought that after several analysts had failed to help her, perhaps a different approach, like CBT, would help. In our first few sessions I used cognitive restructuring techniques to change Priscilla’s negative views of herself.

At her fifth session Priscilla announced that she was terminating treatment with me. I asked her to explain, and she replied that she didn’t like me telling her what to think. In retrospect, a third wave approach that was gentler than cognitive restructuring would probably have been more effective with Priscilla.

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Conclusion

CBT systems, such as those developed by Beck or Ellis use direct cognitive interventions, sometimes called “disputation” or “cognitive restructuring.” But so-called third wave therapies -- DBT, Socratic questioning, ACT, mindfulness, behavioral activation, ERP -- and psychoanalysis as well -- all these therapies dispute dysfunctional cognitions indirectly and gently rather than directly and forcefully. So in attempting to change our patients’ dysfunctional cognitions, we therapists should continually ask ourselves, “Should we use behavioral or cognitive techniques.” And “Should we use disputation or indirect, gentle cognitive techniques, with this patient, with this dysfunctional cognition, at this point in treatment?”