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CHAPTER 12
C ognitive-B ehavioral Therapy
COGNITIVE THERAPY
Cognitive therapists identify, illuminate, and challenge avoidant logical distortions with the goal of correcting specific errors of thinking (avoidant ideation) likely to generate avoidant behavior. The therapeutic goal is to help patients think and act more rationally and productively so that they can more readily connect with others, and even commit to a long-term, lasting, loving relationship with someone special.
Along these lines, Beck elicits, challenges, and attempts to correct automatic thoughts, such as “others view me as socially inept and undesirable,” that lead to avoidant withdrawal, that in turn leads others to counter with “unfriendly . . . behaviors and actions.”1 Beck reality tests these thoughts by asking avoidants to “apply . . . rules of evidence,” “consider . . . alternative explanations,” and solve interpersonal problems by “putting aside the subjective meanings they attach to a communication and focusing on the objective content”2 so that, for example, avoidants can recognize that someone, merely by expressing a personal need, is not per se blaming them for not having gratified it.
Along similar lines, scattered throughout his book, Rapee offers cognitive-reparative approaches to treating shyness and social phobia. These can be paraphrased and summarized as follows:
• learn how to interpret and think about situations and other people more realistically, for example, through learning that feelings and emotions are directly caused by thoughts, attitudes, and beliefs, not by the things going on on the outside
• identify and change basic beliefs and unwritten laws such as “everyone must like me, and if I am not liked, I am worthless”
• identify and challenge basic fears—the things that make you anxious
• don’t overestimate the likelihood that bad things will happen in social situations
• ask, “What is the evidence for my alarmist expectations?” and reassuringly tell yourself, “If the worst should occur, so what?”
• Practice attention-strengthening exercises to help pay strict attention to the task at hand.3
A Case Example
A shy patient hesitated to leave the house because some of his neighbors did not say hello to him on his morning walk—he believed because they did not like him. I helped him reframe his conclusions about the supposedly noxious behavior of his neighbors so that he could become more realistic about this and other similarly terrifying interpersonal situations. I suggested that he apply the rules of evidence, consider alternative explanations, and pay strict attention to the task at hand—which involved focusing on the objective content of what his neighbors were saying, not on the subjective meaning he was attaching to their communications. I clarified that while some of his neighbors might dislike him, others were simply caught up in their own little world, thought he didn’t see them, or, if they did, did not want to call out his name because it was early in the morning and they were afraid of waking up the whole neighborhood. I clarified that his neighbors did not reject him because they thought that they were superior to him, and would not reject him even more when, getting to know him better, they saw his flaws more clearly. I also suggested that when making contact with people, he should monitor his anxiety to make certain that it does not exceed bearable limits, and if it does, he should pull back and try again the next time. For example, I suggested that to avoid creating internal unpleasantness, he should not, as was his habit, discuss politics and religion, but instead promptly switch the discussion to neutral issues such as the weather, or impersonal, unthreatening matters such as the real estate values in the neighborhood.
Some cognitive therapists stress the importance of spotting, identifying, and correcting cognitive errors as they arise in the transference. To illustrate, an avoidant who learned that her therapist was not being critical of her simply because she was correcting her cognitive errors thereby learned that her husband still loved her, even though he didn’t always agree with everything she said.
Some cognitive therapists use role-playing, where they ask patients to put themselves in others’ places for the purpose of developing truer assumptions about what others have in mind. In one case, a patient who felt he was being rejected because he didn’t get an immediate reply to an e-mail he sent was able, after putting himself in the (overworked) recipient’s place, to understand that the response was delayed simply because the person who received the e-mail was currently busy. (I describe role-playing, a predominantly behavioral technique, further later.)
Avoidants, especially those who snap at others in retaliation for imagined criticism, can also benefit from empathy enhancement, a technique that involves reducing transactional negativity through understanding where the other person is “coming from.”
Some Case Examples
Shortly after a man’s wife died, she received a notice from the internist who took care of her asking her to please come in for her annual physical examination. Her husband was outraged at first, but when I asked my patient to put himself in the doctor’s place to explore the possible reasons for the doctor’s confusion, the patient recognized that it was nothing personal and that the doctor, however misguided, was ultimately primarily concerned about his wife’s welfare. So instead of getting mad, and even, he called to tell the doctor’s office that his wife had died, to thank her doctor for treating her, and to commend the doctor for his continuing concern, however misguided, for the state of her health.
A psychiatrist felt passed over when an internist called not on him, but on a psychologist colleague, for a consultation with the internist’s patient. The psychiatrist remained angry until his own therapist pointed out that he, the therapist, knew (for personal reasons) that the internist was merely living out a positive relationship with his own psychotherapist, also a psychologist.
An avoidant vendor out of the morning newspaper reacted to the question, “Do you have any more of these newspapers?” with “It’s not my fault that I am out of them—why is everyone bugging me?” As his therapist, I suggested that he put himself in the place of his customers and see that they were expressing not a criticism of him, but a need of theirs, so that he should instead try a shorter, sweeter, less interpersonally divisive, more accommodating reply: “Sorry, no.”
Some therapists actively suggest positive thoughts patients can install to counter their negative cognitions. For example, a therapist first helped a patient who feared public speaking because he feared he would faint think less catastrophically about what might happen if he actually did faint, however unlikely that possibility. He next suggested that the patient hold a countervailing, distractive, reassuring thought while giving his speech: “my anxiety always dissipates a few minutes after I get started.”
Therapists often help patients think less catastrophically by supportively, soothingly reassuring them that anxiety almost always subsides shortly after a feared activity, such as going to a party or driving over a bridge, begins. What happens is that patients crest over what I call their “phobic hump,” at which time their anxiety diminishes or disappears, to be replaced by positive feelings of mastery, pride in accomplishment, joy in activity, and elated feelings both pleasurable in themselves and a source of motivation and courage to try again.