Encouraged to talk about something distressing, Rebecca described in detail a love relationship that was ending. Cued by her distress at various points in the discussion, I asked about relevant meanings. She located a series of personalized and polarized assumptions with ease. We worked to separate her boyfriend’s contribution to the relationship’s outcome from her own. We labeled the errors in her thinking. She had a surprisingly easy time coming up with alternate ways to view the situations we discussed (Figure 2).
Searching for alternate meanings
Shift of set is another useful approach to disputation. Often a patient has searched diligently for answers to his or her problems and has come up “empty.” The patient many times describes this process as “feeling trapped.” With shift of set, the therapist uses metaphor, humor, or self-disclosure to analyze the problem from another perspective. Asking the patient to comment on the therapist’s “story” often elicits an alternative applicable to the patient’s own circumstance.
Metaphor It is beyond the scope of this article to consider the place of metaphor (or analogy) in psychotherapy. To explore the subject further, you might consult an excellent book by Barker.12
Humor is a useful accessory to disputation in cognitive therapy. Be forewarned, however, that the dysthymic patient may distort the point of the joke and personalize it as an insult. When a therapist is naturally witty or funny, I encourage him or her to use this resource. If not, it is better to avoid attempts at humor.
Self-disclosure Traditional psychotherapy preaches the avoidance of self-disclosure, which risks (even momentarily) shifting the focus from the patient to the therapist and breaking the rhythm of the therapy hour. Even so, I have found that properly thought-out self-disclosure can be useful in cognitive therapy.
Consistent with the power in a shift of set, self-disclosure offers the benefits of surprise, a sign of caring and involvement, and a chance for the patient to learn. A recent report by the Group for the Advancement of Psychiatry addresses self-disclosure in detail.13
Polls and balance sheets At times the therapist may suggest an experiment aimed at generating useful alternatives. Questioning peers or friends (poll-taking) may be one way for the patient to elicit viable options. Another tool for making particularly difficult decisions is a balance sheet (either written or conversational) in which the patient lists the pros and cons of various alternatives. When choices are identified, the patient and therapist typically discuss their consequences.
Resolution: ‘Feeling empowered’
By session four, Rebecca reported using the cognitive method regularly, and finding that she was “no longer accepting the conclusions she used to jump to.” She noticed that when she responded differently, others responded differently to her as well. She was “beginning to feel empowered,” she said.
Figure 2 CASE 1: REBECCA’S TRIPLE COLUMN
Over the next month, I met with her each week. Her mood brightened, and she reported that her energy level was up. She was “actively reviewing her life.” We focused therapy on her self-worth, especially the beliefs that had contributed significantly to it. Upon identifying and examining them, she found that these beliefs were often inconsistent with what she “knew of” herself. We discussed the inconsistencies and worked together to identify alternate views.
She described her views about men in detail. She found several beliefs to be “irrational” and others to represent “poor strategy” if a lasting relationship with a man was an important goal. In the 10th session, she announced that she was “no longer feeling or acting depressed.” She had had an epiphany: “It was all within me,” she said, “not outside of me …. I had kept myself in a perpetual state of feeling diminished and victimized.”
Two weeks later, we met for a final time to review what she had accomplished and to terminate therapy. She expressed amazement that she could accomplish “in 12 short weeks” what had not been achieved in 10 years of work. A follow-up call 6 months later found that her gains had been maintained.
Comment When an automatic thought (meaning) is identified, the next step is to test its usefulness for the patient. I encourage my patients to consider two key criteria: rationality and strategic worth. First, does the meaning make sense? Often, when examined in this way, it does not. Second, even a rational meaning may not serve the patient’s purpose. It may represent a poor strategy, unlikely to help the patient reach his or her goal. If the patient judges the meaning to be inadequate, we work together to find alternatives. We treat these options as choices and consider their consequences.