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Post-Cognitive Psychotherapy

Mark Dombeck, Ph.D.

Both ACT and Schema Therapy are what you might call Post-Cognitive Therapies. I tend to hate it when people start using phrases with "Post" as a prefix. I still don't quite know what the popular term "Post-Modern" is supposed to mean, for instance. I figure if I'm going to create a term like "Post-Cognitive Therapy", I ought to offer some explanation for why that term seems to fit. In order to do that, I need to briefly discuss ACT and Schema Therapy in the context of the history of psychotherapy.

Cherry blossom in spring against a blue sky

People use the term "psychotherapy" like it refers to a single thing, but that is not at all the case. There is not one form of psychotherapy but rather, many different forms. All of the forms of therapy that exist today are the products of an evolutionary process. Each generation of psychotherapy reproduces and births new forms which are, variously, similar, or very different from their predecessors.

In the very beginning, there was only psychoanalytic psychotherapy, the creation of the seminal Dr. Freud. The early psychoanalytic therapy attracted legions of followers, but many critics too. Some of those critics went on to formulate their own forms of psychotherapy.

Some of the early post-Freud forms of therapy were similar in nature to Dr. Freud's vision; evolutionary extensions of it if you will. For the early Freud, the activity of therapy was to be concerned with uncovering unconscious thoughts and wishes which were the root cause of neurosis, and with taming the animal urges. This emphasis on helping patients gain insight into intra-ego struggles gave way in a later generation of analysts to a focus on what has come to be known today as Dynamic (or Psychodynamic) Psychotherapy, and also as Object Relations Theory/Therapy, all of which concern themselves, more or less, with helping patients gain insight into inter-ego struggles; insight into the relationships between people as they are represented in patients' minds.

Some of Freud's critics liked the idea of psychotherapy in general, but entirely rejected Freud's concepts and philosophical basis for how to perform therapy, substituting instead alternative philosophical bases and techniques. Behavior Therapy was birthed when American psychologists applied psychological learning theory to the process of psychotherapy. Family Systems Therapies were birthed when ecological and networking principles gleaned from Biology, Sociology and various communications theories were applied to psychotherapy. The Humanistic Therapies (such as Gestalt Therapy and Client-Centered Therapy) were created when European existential philosophy met Buddhist/mystic-style mindfulness. Some of these therapies have, more or less, gone out of business (Only a handful of practitioners would call themselves Gestalt Therapists today). Those forms of therapy that remain today have evolved. Most famously: Behavior Therapy begot Rational Emotive Therapy (RET; later REBT) and Cognitive Behavioral Therapy (CBT), and for a variety of reasons Cognitive Behavioral Therapy ended up dominating the therapy scene in America. For perhaps the last twenty years, Cognitive Behavioral Therapy has been in ascendence, at least in America, with only minor challengers to shake things up. It's not that the other forms of therapy are not still practiced extensively; they are. It is more like CBT has been the only therapy that has really been considered state-of-the-art in a mainstream sort of way.

Though change in the world of psychotherapy is slow moving, it is also relentless, kind of like a glacier carving its way down a mountain slope. The heyday and dominance of purely cognitive behavioral forms of psychotherapy is shortly coming to an end, I think, if it hasn't happened already. Though arguably offering a better (more effective) therapy experience than its predecessors, it has become apparent that CBT has limits and does not represent the final word on how to do therapy. Leaders in the field of psychotherapy, like Dr. Young and Dr. Hayes who we've recently interviewed have long been busy pushing on the frontiers and their efforts are presently bearing fruit.

Dr. Jeffrey Young's Schema Therapy represents a creative integration of ideas from cognitive behavioral therapy and from object relational forms of therapy. Dr. Young trained with the founder of CBT, Arron Beck but came to see that, as powerful as CBT is as a means of facilitating patients' positive change, it is not particularly useful in its pure form for helping some classes of patients with long standing developmentally based relationship issues such as personality disorders.

The core technique characteristic of Cognitive Behavioral Therapy is the analysis of appraisal, usually taught as Cognitive Restructuring, or Cognitive Reframing. I've described this technique elsewhere, but in a nutshell it involves teaching patients to become aware of their automatic thoughts and core beliefs concerning themselves and their situations, and to use this newfound awareness as an opportunity to closely and deliberately examine beliefs and judgments, looking out for systematic, habitual sources of bias and error. Those thoughts and beliefs that are found to be biased are then challenged and "reframed" or edited to be more consistent with reality. For example, if someone has a social phobia and cannot cope with public speaking tasks, they can examine their thoughts and beliefs concerning the dangers they think are to be found when public speaking. Any dangers that are identified can be carefully considered to see if they are real dangers or just imagined ones. Any imagined or exaggerated dangers can be challenged and ultimately become less frightening.

Cognitive Restructuring works great when patients are able to calmly and dispassionately consider their automatic thoughts and biases. Some patients are more easily able to do this sort of thing than others, however. Certain patient groups don't do dispassion very well. Rather, they live their lives in a more emotional and impulsive mode. They are hard to help with traditional CBT alone.

When I say that problems like Borderline Personality Disorder are developmental in nature, what I mean is that they are the result of difficult and sometimes traumatic early relationships, sometimes beginning as early as infancy. Such patients' early relationships were disturbed, sometimes abusive and violent, and as a result, their conceptions of the nature of relationships in general mirrored this disturbance. Later life relationships tend to build on the success of earlier life relationships. Because borderline people learn to expect damaged relationships as their lot in life, that is what they tend to recruit and recreate. Not unlike a blind-from-birth person failing to understand the concept of color, someone who has never had the experience of loving parenting will not know to miss it.

Early relationships set up not only expectations for later life relationships; they also provide a mirror for the development of self-concept. Based on early experiences of unfulfilled promises and failed attachments, many borderline diagnosed individuals conclude that they are, in fact, abandonable. This sense of being abandonable becomes a pervasive, if invisible, theme in the lives of many borderline diagnosed individuals. It is this pervasive sense of being abandonable that Dr. Young characterizes as a schema; one of many schemas about the nature of self that people may form. It is in part because of this schema of being abandonable that becomes embedded into patients' self-concept that patients end up becoming vulnerable to recurrent depression and impulsive, self-destructive actions.

Where traditional CBT would target thoughts about depression with cognitive restructuring exercises, Schema Therapy tries to go deeper so as to uncover the root problem, the maladaptive self-schema itself, and then target that schema with restructuring exercises. Experiential exercises drawn from past humanistic therapies such as Gestalt Therapy, and designed to trigger emotional responses are used to deepen the understanding of the schema; to help the patient appreciate their maladaptive schema not as an intellectual exercise but as a felt and inhabited reality. An abandonment schema is not just the intellectual belief that you are abandonable; it is also the very physical and painful memory of what it is like to feel the abandonment. Such schemas are sewn together from pain and tears as much as anything else, and to uncover and appreciate them requires that such feelings are re-experienced to some degree.

As patients become more able to comprehend and tolerate their maladaptive self- and other-schemas, a space opens up where they can start to do cognitive work on those schemas; to closely examine them for signs of bias, overgeneralization, mischaracterization and other errors that can lead a person to come to wrong conclusions and thus act in maladaptive and mistaken ways.

There is no native tradition of examining self and other relationship schemas in cognitive behavioral therapy. This idea has been borrowed from object relational and psychodynamic forms of psychotherapy where it has been popular for decades and decades. For instance, the concept of transference is entirely based on the idea of schemas (although psychodynamic therapists have not traditionally called them by that name, preferring instead terms like "objects", "object-relations" and "role-representations"). It is exactly a schema concerning expectations of how one person will treat another that gets transferred from an earlier relationship to a later one in transference. Because of this borrowing from object relations based psychodynamic therapies, Schema Therapy cannot really be thought of as a traditional Cognitive Behavioral Therapy. It is instead something that has evolved from a base of traditional Cognitive Behavioral Therapy, and that is why I am referring to it as a post-cognitive therapy.

Like Schema Therapy, Dr. Steven Hayes' Acceptance and Commitment Therapy (ACT) is also a Post-Cognitive Therapy, but arrives at that place in a different manner and with different emphases and borrowings.

Acceptance and Commitment Therapy is founded upon what I think are profound insights into the nature of human suffering that Dr. Hayes developed based on his experience doing basic research in animal learning and human language. Dr. Hayes' foundational insight was that people are fundamentally not designed to be able to easily tell the difference between reality as it actually is and reality as they think it is. They cannot easily tell reality from fantasy; particularly when they are fearful of experiencing the consequences that might come from testing their assumptions. The reason that this is so is because all human beings experience reality through the lens of language and the power of language to represent experience with symbols. All human experience is mediated through symbols, and symbols are never perfect reflections of reality.

Humans are unique in the animal kingdom in that they have language. Other animals (like dogs) can learn to associate sounds with behaviors, but only human beings truly understand language sounds symbolically. When an infant person learns the word "ball", she comes to understand that the world ball is a symbol for (represents) a physical object in the world that you can play catch with. Using language symbols, human beings are able to create elaborate maps (or schemas) of the things in their environment, including maps of the people in their environment and how they behave. They can even create maps of themselves (what we typically call self-concept). There is a purpose to all this symbolic mapping behavior; it enables people to solve problems in a very efficient way. People can imagine their representations of things in the world, alter those things in their minds' eye and visualize what the changes would be like. In other, simpler, words, they can ask "What if ... ?". Symbols further enable people to represent and remember past experience and to imagine future experiences that have not occurred yet.

Herein lies the problem. People confuse their symbols for the experiences those symbols represent. They imagine an airplane falling out of the sky and refuse to fly. They imagine that all men (or all women) are jerks, based on prior experience with one or more jerky men (or women) and refuse to date. They stay in relationships they do not really feel good about on account of their paralyzing fear that nothing better could come along for them. They fail to pursue opportunities they are interested in because they fear failure, or disappointing someone they feel dependent upon or loyal to. Sometimes these fears are justified, but sometimes they are only imagined, and inaccurately so. When this latter possibility happens, people's opportunities, possibilities and behaviors become unfortunately narrowed because they cannot accurately distinguish between fantasy and reality.

The traditional cognitive behavioral approach to this fundamental problem is to teach people to become better at examining their perceptions, judgments and beliefs for errors and eliminating those errors. This logical, rational and systematic approach works for many people, but there are many other people who have severe difficulty engaging in this process because they are too distracted by their erroneous beliefs and the powerful emotions and impulses that occur as a result of those beliefs to make it work.

Hayes' approach to working with such patients involves helping them learn to disengage from taking their own thoughts too seriously; helping them develop the capacity to step back from and just watch their thoughts and perceptions go by, without feeling the need to act on them. He uses a variety of techniques, many experiential in nature rather than conceptual, to accomplish this process of helping people detach themselves from their symbols; to stop identifying with their thoughts and start experiencing them as something separate from themselves instead.

Hayes uses images, stories and phrases to encourage patients to take up a desirable observational and detached stance towards their own thoughts. A patient will come in and say something like "I'm afraid to fly! The airplane will fall out of the sky!" A traditional CBT takes such thoughts seriously and might say in return, "What evidence do you have to think that is the case?" An ACT therapist, on the other hand, works to undermine the habit the patient has of taking his thoughts seriously in the first place. "Interesting image!", he might say, "What other entertaining thoughts has your mind produced today?" The ACT therapist is not making fun of the patient's panic, or failing to realize that crashes can and do happen from time to time. Instead, he is working to help the patient cultivate a kind of relaxed, non-judgmental detachment.

The cultivation of detachment towards one's own thoughts is a stop on the ACT journey, but it is not the destination. Detachment enables patients to come to a new relationship with their thoughts. In their initial un-detached state, patients react to their thoughts in knee-jerk fashion, in intense, impulsive and often quite unproductive ways. With a more detached attitude towards thoughts in place, patients become more able to tolerate and accept those thoughts (rather than needing to simply react to them immediately). With acceptance and tolerance patients gain the ability to become more discriminating about how they will act. They gain the ability to become more proactive and less reactive. Their actions become less frantic and more values-driven. They gain the stamina and stability necessary to make a commitment to learning and practicing techniques that can help them grow in areas they need to address. Patients arriving at this values-driven, motivated place might then be exposed to techniques might be drawn from the Cognitive Behavioral Therapy repertoire.

There are other post-cognitive therapies out there besides Schema Therapy and ACT. The most famous one is an approach known as Dialectical Behavior Therapy (or DBT), championed by psychologist Marsha Linehan starting in the 1990s as a useful approach for working with highly emotional and volatile patients such as those who present with Borderline Personality Disorder. DBT shares in common with ACT an emphasis on the need to cultivate mindfulness (the label often used to described the detached, non-judgemental state of mind cultivated by ACT), although these therapies are otherwise not terribly similar. Perhaps we'll be able to do a podcast with Dr. Linehan or another senior DBT researcher in the near future and highlight this important newer form of therapy as well.

It's not just cognitive behavioral therapists who have been creating "post" therapies, either. There are also psychodynamic therapists who are pushing the boundaries of traditional psychodynamic therapy into post-psychodynamic territory. I'm less familiar with this side of the house (being primarily post-cognitive-behavioral in orientation myself), but I will point out the genius work of psychiatrist Mardi Horowitz whose edited book Person Schemas and Maladaptive Interpersonal Patterns came out in 1991 (!). Doesn't that title sound like something that Dr. Young might have written last year? Back in those dark days when I was still wet behind the ears in graduate school and Schema Therapy was but a gleam in Dr. Young's eye, Dr. Horowitz was already busy building a bridge spanning object relations and cognitive psychology. I'm going to invite Dr. Horowitz to do an interview with us for Wise Counsel soon. If we're lucky and he'll do it, I think that'd be an interesting show.