Cognitive Processes and Emotional Disorders: A Structural Approach to Psychotherapy 0898620023, 0898620007, 0898620015

Citation preview

COGNITIVE PROCESSES AND EMOTIONAL DISORDERS

THE GUILFORD CLINICAL PSYCHOLOGY AND PSYCHOTHERAPY SERIES MICHAEL J. MAHONEY, EDITOR

P AJN AND HEHAVJORAL MEl)lCTNR A COY V . .F. (;uidano and(;. Liotti Alutions "'t.hcr-Jpiscs.·· • ioC'c it sfanning a Thcrnpeuric Strategy, 299; Notes, :1>05

In Conclusion

307

AppcnJi.x A. The , rrncm.re of Psychiarric Knm leJge and the Problem of Prcmorbid. .Pcrs

Appeotli x R. The P:lti ·nc S:unpli:

21

Rcf •rcnces lnd.ex

337

'j

i

''i

t

(

I

I

!

'

l

"

,,

,,

PART O

E

;:'. 1· ....·, ,;

THEORETICAL FOUNDATIONS

,,

::

I

I

I

,.

------- -

____

__ __________________________

.,_____,......__....._

.;...._

1 HUMAN KNOWLEDGE: SOME EPISTEMOLOGICAL AND PSYCHOLOGICAL NOTES

GENERAL REMARKS

AN EVOLU11ONAR Y VIEW OF '£HE RELATIONSHIP BETWEEN COGNITION AND REALITY It is almost a truism of modern biolo.1-,,y chat human beings are the prodw;c of a Jong evolutionary hiscory wh ich began millions of years ago from simple uoiceliular organisms or ·virus-Like aoce ·mr · an0ceprual framework that i able to provide us with a satisfacrory model of the relationship b tween tacit and explic.it knowledge. In chis section we will attempt to catch a glimpse of this relationship, considering how the djscinccioo between the two types of knowled ,e origioates. Ffr c, we will deal with thee olutionary iewpoiac and then will see how ca,it and explicit knowledge are developed and artirnlated in a single .individual' · ontogeny.

1 he Evolutionary Perspective l:?rom an evolutionary viewpoint, the problem of distinguishing rwo kinds of knowledge only comes up i.n the human species, and it is pre umably cuonecred to the on et of language and the hemi pheric specialization.

__. ....-. --

- - - - - - - ·· - ··-- ··------ - '.

10

- --·-·~-'- ~· ~l

THEORETICAL FOUNDATIONS

The studies carried out by Sperry and his associates (cf. Sperry, 1974) on patients whose corpus callosum was sectioned in the treatment of intractable neurological diseases (the so-called split-brain patients) have furnished extremely interesting data on the functional organization of the human brain. Among these, the discovery of the uniqueness and exclusiveness of the left hemisphere with respect to conscious experience is particularly noteworthy; that is, although the right hemisphere was still able to _carry out skilled and purposive movements, especially in the area of spatial and pictorial tests, it became completely incapable of furnishing any conscious experience of its activity. Therefore, with a good approximation, one could come to the conclusion chat the right hemisphere's activity in normal persons reaches consciousness oIIly by transmission to the left hemisphere through the corpus callosum. Thus the capability of conscious experience seems to be the- exclusive prerogative of the left hemisphere, which contains the linguistic areas. This hemispheric specialization is unique to human beings; in fact, the homologous cortical areas of primates do not show any evidence of functional asymmetry (see Eccles, in Popper & Eccles, 1977, especially Chapters E5 and E6). It is also probable that such hemispheric specialization has been produced during human evolution in response to the unique demands and the specific pressures imposed by the onset of the unprecedented evolutiona~y possibility represented by language. . Unlike the sharp and immediate messages that animals give and receive, language offered the human species the possibility of a disengagement from the context through which the potentialities of exploration and control of the environment changed significantly. According to Bronowski and Beilugi (1970), the properties of language chat have permitted the attainment of such a disengagement from the immediacy of environmental stimuli can be schematized in the following points: • -Delay between stimulus and utterance of the message chat the stimulus provoked • Separation of the emotional or affective component from the specific content transmitted by the message • The prolongation of reference, that is, the possibility of using specific messages backward and forward in time

f f.

~

! t

,--HUMAN KNOW1.EJ)(-;J 1•

11

• lncernalizarjon of language which thus became not only an in trnmem of ocial communicarioo, but also. n instrument of reflection and explorarion that the individual cou1J nse io elaborating va.rious hypotheticaJ messages before choosing the one he or she belie ed SLLitable. Furthermore, these points ar all pare of what is surely the:! most important propeny offered to tl1t! human mind by language: being able to rcify exp rieoce, strucruriag it in elemeors, , hich, a concept · have scabiJjty and consistency aod can therefore be manipulated oo the same Level as real objects. With this capaci.ty for reifying experience, the human species not only reaches an unpret·cdented level of diseogag meat from the wnrext but also acquires new po sibilitie for controlling and influencing its own cnvirorunem, as a re ulr of an ever-increasing leve l of comp.rehensi.on of omside reality. Tht1s the possibilities tbat ha e been created by tbe oos t of language can justify bow the left hemi.-;pbere, more verbal and logicaJ than che right, has progressively b omc ch center of oosc.ious control and experience. _ However, chi does oor mean cbar the forms of prelogical "thought'' produ d during rb long evolutionary procc shave b come exrjnct or even arrophied . As Tenber (197/4} cogently argues the concept of a unilateral dominance of the left hemisphere over the right should be abandoned and substituted by one of a complementary specjalizarioo. Furthermore it is possible chat from. the beginning the · functional complementarity of a left hemisphere specjalized in analytical and logical casks and a right hemi phere specialized in synthetic and holistic ta k has notably increa eel the po · ibilities of adaptive adequa y. Therefore what has probably been produced i a new funcrional integ ration, where the conrrol of rhis comp! mentary peciaJizario~ wa assumed from the emerging higher cortical func cion . In other words, it is a if a kind of "choice of the pecie ·· occurred in which the control over eovi.wnmenrnl exploration was assigned to the log ical -conceptual rnp.tbiliries that appeared and to the new ossibilities that they offer d. Oo the other hand since the forms of prelogi al knowledge-which cannot be verbaliz d aod therefore are es entially tacit-have a.ppeared much earlier in the course of evo lution one C. That it is an inscam:c of cxm.:tnt' avoidance beha vior.

Clinical observations quickly reveal that tbe first two hypotheses apply, at mosr, to a very Llmjtcd nmnbc.r of depressed paticnrs. Jlrequcncly. t he patient's rclarives, airer a brief pcriod of compliance, ceacr nega tivdy to the patie nt's ap athy: Heiog admitted to a ps·ychiarric

ward is not a reward for one's inertia. D uring the period of wirhdrawaJ and passivity, the patient _genuinely suffers (he or she may even commie stLicide!) , which is hardly to be cxpernxl fo positively reinforced behavior. The loss of imprwoc sources of rcinforccmeot applies only to those instances of depression that arc a reac.:tion to bereavement; we muse also remember chat there is a d iffcreoc.:c between normal grief and d lnirnl. depression: 1 The hypothesis char the pa tie nt' s withdrawal, _passiviry, and behavioral retardation could be considered as forms of avoidance behavio r deserves more at.tenrion. le is possible thacallenvironmeocal sinrntions char formerly gratified rhe patient ha ve acquired a punishing tinge, so chat the paricnr actively rries to escape from o r avoid ther:o. This is indeed the impression o ne gees while examining the w ay in which be or she has ''given up." Beck's description of the stages through which the depressed person a rrives at almost total inertia is enlighteojng:

_____

-

174

• • • .: •

- - - ··--- -

-- - · -.- •

. -. --

_

, _ . c ••

. ...

- - .. --- ·-- ---~ --~ -~- ~~~

CLINICAL APPLICATIONS

, I I

He no longer feels attracted to the kinds of enterprises he ordinarily would undertake spontaneously. In fact, he finds that he has to force himself to engage in his usual activities. He goes through the motions of attending to his ordinary affairs because he believes he should, or because he knows it is "the right thing to do, " because others urge him ro do it- but not because he wants ro. . . . He feels a strong drive to avoid "constructive" or " normal'" activities. . . He may feel repelled by the thought of performing even elementary functions such as getting out of bed, dressing himself, or attending to· personal needs. A retarded, depressed woman would rapidly dive under the bedcovers whenever I entered the room. She wo1tld become exceptionally aroused and even energetic in her attempt to escape from an activity that she war pres.red to engage in . . . . People generally try to avoid simations they expect robe painful; because the depressed patient perceives most siruacions as onerous, boring, oi: painful, he desires to avoid even the usual amenities of living. (Beck, 1976, pp. 121 - 123; italics added)

Beck's observation of the depressed woman's energetic attempts t0 escape makes a point that is difficult to explain either by the learned helplessness hypothesis or by the hypothesis that psychomotor retardation is a consequence of a primary biochemical defect in depression (the "physical depletion·· hypothesis). Our .observations are in accordance with this: Depressed patients seem to have "energy," but choose not to use it, except when they are pressed to give up their "apathy." In such cases, in contrast with Seligman's dog, the patient does "jump the barrier" and escapes from what he or she seems to consider the more painful "shock," that is, tO engage in some "constructive" activity. Even suicidal behavior may be regarded as an extreme escape or avoidance behavior: It is the only way to escape from actual suffering and to avoid the future burden uf a hopeless and painful life (see Beck, 1976, pp. 123-124, for some examples of how depressed subjects justify their suicidal wishes). Naturally, still to be explained is how environmental situations that were once pleasant or neutral acquire such punitive and repulsive attributes for the patient. No environmental antecedents justify such transformation in the clinical analysis of all our patients. (Obviously, were human beings to come up against such environmental transformation as to cause the whole world around them tO have objectively repulsive features, we would consider neither their inertia nor any attempted suicide as abnormal behavior.) It seems, rather, that depressed patients have in some way decided that passivity and with-

DEPRESS[ON

175

drawal a.r e the best-or the least bad-solutions to their problems. To know what th problems are, we must proce d to analyze patients' cognitive contents or processes. However, before presenting the cognitive- functional analysis of depression, we must fmther examine a secror of the patient's experience that will make it worthwhile to carry out a sequential analysis in terms of environmental antecedents and consequences, namely, his or her emotional reactions and related inrerpersonal behavior. The reconstruction of the sequences of environmental antecedents and emotional responses during the first psychotherapy ses sions wirh a depressed patient is useful from the point of view of clinical assessment-furnishing, as .i t does, the basis for the identifi ca tioo of mediating cognitions- a od from the point of view of therapy. ln fact, the depress d patient often states in his first interviews that "et·erything makes him suffer"; "he is alway.r sad''; "be can't stand any novelty" ; he is irritated or cries "over a trifle" ; he feels "anguished by everything''· he is "always ill"- all of which is "probably co be attributed to some deficiency, fault, or incurable disease" of his. When asked ro give clear examples of his negative reactions and to consider to what kinds or mixtores of basic feelings (sadness, fear, or anger) his emotionaJ distress can be compared, the patient discovers with the therapist that, in the apparently uniformly gJoJmy picture of his existence, some se.lective responses and exact kinds of situations really do emerge. Usually one can observe that depressed patients overreact to environmental events connoting rejection or loss. Reaction i.s anguish or sadness, sometimes preceded by anger. It can also be observed that, in simacions where there is an environmental influence pressing patients out of their inertia, they react with anxiety (if they consider that action is the " right thing to do") , anger ( if they feel unjustly pre. sed on t0 aetion by others ), or a mixture of these two basic emotions (the most frequent reaction). The following exarpp.lcs 1nay illustrate this poinr:

Example l John, a mildly Jepresscd 38-year-nlPcar bright and b amiful) bad things (divorce, ra1nbuflc.:tiou d1i!dren won' t happen to me" (Beck u/ ,,.t., 1979, Chapcer 12 , Figure .\ italics aJ.ded). It: seem · to us that su ha pari or must have had th diffo.T1lries of life (mostly lo ses) in mind and rhen resolved char a strenuous _prevenrivc Hort was robe m, de .

at "'·

184

CLINICAL APPLICATIONS

Beck's cogent considerations of the strict relationship between the "personal domain" and the specific content of the "cognitive triad" are also pertinent to the topic; the same applies to Beck's explanation of the self-reproaches, as follows: In reviewing the histories of depressed patients we often find that the patient has coun~ed on the accribme chat he now debases for balancing the usual stresses of life, mastering new problems, and attaining imporram objectives. When he reaches the conclusion (often erroneously) that he is unable ro master a serious problem, attain a goal, or forestall a loss, he downgrades the asset. As this attribute appears to fade, he begins to believe chat he cannot gee satisfaction out of life and that alJ he can expect is pain and suffering. The depressed patient proceeds from disappointment t0 self-blame to pessimism. (Beck, 1976, pp. 114- 115)

We would like to avoid a full discussion of the links between the depressive cognitions and their em.otional consequences; the writings of Beck (1967, 1976) and Shaw (1979) could be consulted for this purpose. We shall limit ourselves to some brief summarizing notions. 1. The perception of loss prod_uces feelings of sadness. Studies of bereavement and grief (Bowlby, 1961, 1969, 1973; Parkes, 1972) strongly support the notion of an "unconditioned" relationship between loss and sadness. Anger appears as a component i.n the process of mourning, but is not at all the antecedent of sadness. (According to Freud, the sequence is: unconscious hostility toward the deceased love object - guilr and anger directed toward the self sadness.) Even taking into account the difference between actual and imagined losses, it is obvious that, if loss and loneliness dominate depressives' representations of themselves and the world, they will feel uniformly sad. 2. It is possible to distinguish feelings other tha.n sadness in the depressive's daily experience: Anger directed coward self and others and fear are perhaps the most important. These specific feelings are elicited, in daily experience, by selective stimulus situations and are mediated by the patient's belief system. Useful information about the patient's idiosyncratic cognitions, particularly about the content of his or her "shoulds" (rigid rules for living), can be obtained by an analysis aimed at these specific feelings. It is important tO recognize explicitly that io our cognitive model sadness is the "primary" feeling in

Dlil'RE"SIO

r

J 85

tlepres ·ioo; that is it is nor secondary to aogcr or fear, as ic is as. tuned in much of the psycb.oana.ly-tic r 1t1ng. 3. Anger, fear, und sado(;sS are conn · ·ccJ ro specific belief , and chei.r relationships are understandable in terms of tbe rdario~ hips among beliefs that constitute the cognitive stntetnre. A hierarchical organization io which personal ideociry plays a central rule is a better way of conceptualizing this srrncrnrc cha.n as a d1ain of6. 9[ (Beck's depressed subjects) anfollow the suggestion, the c.heGtpist asks tbc parieor rn detail the reasons for bis rdnctaocc." We .rernmmemi chis method of assessment only if the behavior,t.l _prescri ption is compatible wi.th the str.awgic pl.t.ll of psychotherapy. 7. The first three catcgrics wnstitmc wb,1t .Beck (1967, 1970) has called the "cogni tivc tri.td of depression."' W c h.ivc nscd Heck.·s termino logy i.n listing chem and have pnr chem -i.o ao urde.r: that, acconling m our own di.meal experience, r.tmghly parnUcls the seriousness of the depression. That is, wh en depressed pati ents ar c ,1skcfn, 1)178, 85, 531· 55-i. K ljogcr, E. fnrng-inal procc,scs: A g limpse of th.:: P,:omisL:tl .Laud. In M . J. Malwnq• (hi. ). l's;dJothc-r.,J>r prixess. cw York: Pkonm, 1980. Knrzybski, A. S!'ien,:e ,111d JM1-·i ty . An int·rod11uion 1-0 no-11. /l -ri.rtor.clian srst-c-m ,i;1J. gen,?·m./ .,em.,1.-1uiu . N1:w Yo1:k L:11.Kas tc·r. Press, 19,J.1. Kovacs, M ., & Heck .1\. . T . Cogrur.ivc~,tffccci11c pmccs~cs u1 depressioo. To C. E. lzanl (fal), Emotion in pcr.ro11ali1:7, and psy,:hop,itholog_y. New York: Pll·m1m, J>179 . Kttlll.l , T. S. 'J.'h c .rtntct1M"C of J,:ieutifi,: re-11ol1r.tions. Cl1irngo: U nivcrsi,y of Chicago l'.rcss, 1%2. l.,unb, M . K (Ed.). The roiJiq11iat-rica ,-1 rge11-tinJ .m,/. beb.wiof r.h.11jge. ew York: W il ·r, 1971. Turner, R. f., . tckc1ce, :,., , .Foil, E. F ai: of ci:i1icism iu wa. he:i:., checker. ~nd phohi ·. &haviou-r R r. e.1r .h ,1-tul Th,. ·,,pJ'. 1979, 1". 79--Rl. 'J'w,.cy M. T . Cou~rnKtivl LhCO L)' perceptual . rstcms aud ra ' t ki1o tvledge. Tit '. . It ' cil1 er .J D . .'. P :iknno (F.d..). Cogniiion .in.I the' 1_1,mbolic pror. 1su. l IiJlsdalc::. J.: 1-: db uru, 1 7-L Tw ·ncr, R . D ., obcny. L E .,, Mrn.m, C. R. ( F.cu .) . On rcie.'Tl-tific tbinking. l ' Yor:-· Cohunhiil [ nive.['. iLy T'r ' !.S, 1981. alkcr V. J. An -i-,weJtig,1.tion of 'rit.r1a!irtic beh,ivior,r in ob.r,· .r-iu11,1I p,1tienn C upnhl' s!lL- wcsi, L1~rirn1c of P~r hiairr, lTuin ' r,ity of Londou, 1967. ('Kxtcusi,·cl · q11n1cd i11 H . Jt. Be d 1 [ Hd.), ObJ .s ional st:1tn. Chaprc1: 6. Loudo n: M i:111 co, 19 ' .) "\ ason. P . ·. O it rhc failure L di.01io..uc lirpo t.l1es·s .. . :