George Kelly’s personal construct theory goes beyond the cognitive elements addressed by social learning theorists and provides a full-fledged cognitive theory. Kelly believed that individuals act very much like scientists studying personality: they create constructs, or expectations about the environment and people around them, and then they behave in ways that “test” those beliefs and expectations. For Kelly, the personal constructs are more important than actual reality, since it is the construct that guides cognition and behavior, not the actual situation. His theory was unique, and quite unrelated to others that came before and after. This was, in part, Kelly’s very intention:
It is only fair to warn the reader about what may be in store…the term learning, so honorably embedded in most psychological texts, scarcely appears at all. That is wholly intentional; we are for throwing it overboard altogether. There is no ego, no emotion, no motivation, no reinforcement, no drive, no unconscious, no need…all this will make for periods of strange, and perhaps uncomfortable, reading. Yet, inevitably, a different approach calls for a different lexicon... (pg. x; Kelly, 1955a)
Albert Ellis and Aaron Beck are best known for developing therapeutic techniques that are based on a cognitive perspective of personality and behavior. Although they are not known for developing actual theories of personality, their clinical approaches are based on underlying theoretical perspectives, which shed light on how they view the nature of personality. Thus, their influential work is naturally connected to that of Kelly, whose theory of personality was entirely cognitive (as compared to the cognitive social learning theorists Bandura, Rotter, and Mischel). More recently, there have been cognitive approaches to therapy put forth that are connected to much older approaches to human understanding. Acceptance and Commitment Therapy (ACT) takes an experiential approach to changing behavior that shares many similarities to Buddhist approaches (Hayes & Smith, 2005; Hayes, Strosahl, & Wilson, 1999), whereas Radical Acceptance relies directly on Buddhist teachings to encourage people to embrace their own lives (Brach, 2003).
Personal Construct Theory
Kelly’s personal construct theory departs from cognitive social learning in that he proposes it is not simply enough to know what a person is likely to do in a given situation, even when your predictions are correct. More importantly, we need to know what a person might have done (Kelly, 1966). Thus, unlike the cognitive social learning theorists who consider cognitive processes as an aspect of the environmental circumstances associated with behavior, Kelly focused on the cognitive constructs first and foremost.
Kelly presented his personal construct theory in a two volume set, which was published in 1955 (Kelly, 1955a,b). In the mid-1960s Kelly was preparing a new book that was to include talks and papers he had presented around the world, many of which were never published. Unfortunately, he did not survive to complete this task, but the project was later completed by Brendan Maher (Maher, 1969), thus furthering the information available on this unique theory.
Brief Biography of George Kelly
Not much is known about George Kelly as a person, particularly regarding his childhood. Later in life he instructed his wife to destroy all of his personal correspondence. Thus, it has been somewhat difficult to piece together a picture of how this fascinating individual became the man he was. He was born in 1905 on a farm near Perth, Kansas. His father had been educated for the Presbyterian ministry, but after getting married his parents moved to the farm in Kansas, where they had their only child. The Kelly family moved around from farm to farm, including a failed farm in Colorado on some of the last free land given to settlers in the West. Kelly’s education was erratic, and he learned what he could when the family would occasionally spend a few weeks in town. He attended four different high schools, and apparently never established any long-term relationships. He was, however, favorably influenced by the exciting stories told by his maternal grandfather, who had been the captain of a sailing ship in the North Atlantic (Fransella, 1995).
Despite his erratic education, Kelly attended college at Friends University and then Park College, where he received a Bachelor’s degree in physics and mathematics. Despite studying math and science, the collegiate debates he experienced had sparked a keen interest in social problems. So, he entered the University of Kansas to earn a Master’s degree in educational sociology, and in 1927 he completed his thesis on the distribution of leisure time activities of workers in Kansas City. He then moved to Minneapolis and supported himself by teaching one night a week in each of three different night schools. He began studying sociology and biometrics at the University of Minnesota, but when the university found out that he couldn’t pay his tuition he was told to leave. He was then hired to teach psychology and speech at Sheldon Junior College in Iowa, where he spent a year and a half. He then returned to the University of Minnesota for a semester of studying sociology, but then went back to Wichita, Kansas and worked as an aeronautical engineer for a few months. He then received an exchange scholar fellowship to study at the University of Edinburgh in Scotland, where he earned a Bachelor’s degree in education in 1930, having written his thesis on predicting teaching success. He then returned to the United States, attended the State University of Iowa, and in 1931 he received a Ph.D. in psychology, with a focus on reading and speech disabilities. Two days later he married Gladys Thompson (Fransella, 1995; Maher, 1969).
As uncharacteristic as it may seem, Kelly finally settled down. He spent the next ten years teaching at Fort Hays Kansas State College. His research and writings during this time focused on the practical aspects of providing clinical psychological services for schools. Much like Alfred Adler had in Austria, he developed traveling clinics to provide training around the state of Kansas, and his model had a dramatic influence on the future of rural school psychology. With the advent of World War II, however, Kelly entered the Navy as an aviation psychologist. At first he helped to train local civilian pilots, but then he transferred to the Bureau of Medicine and Surgery of the Navy in Washington to help select naval air cadets. After the war he spent a year at the University of Maryland, but in 1946 he was appointed Professor and director of Clinical Psychology at Ohio State University, where he spent the next 20 years (Fransella, 1995; Maher, 1969).
During his first few years at Ohio State he focused on making their clinical psychology training program into one of the best in the country. One of his colleagues in the department was Julian Rotter, also known for his role in shaping the training programs used in psychology today, and one of their students was Walter Mischel (who admired both Rotter and Kelly). Kelly then turned his attention to the theory that made him famous, the two volume work entitled The Psychology of Personal Constructs (Kelly, 1955a,b). Kelly’s theory gained immediate recognition as both unique and significant, and he was invited to teach and lecture around the United States and in Europe, the Soviet Union, South America, Asia, and the Caribbean. He was elected president of both the Clinical Division and the Consulting Division of the American Psychological Association, and he served as president of the American Board of Examiners in Professional Psychology. In 1965, Kelly left Ohio State for Brandeis University, where he was appointed to the Riklis Chair of Behavioral Science. He began working on a collection of his papers and lectures from the past decade, but he died unexpectedly in March, 1966. As mentioned above, that collection of works was completed by the man who succeeded Kelly as Riklis Professor of Behavioral Science, and was published under the title Clinical Psychology and Personality: The Selected Papers of George Kelly (Maher, 1969).
Placing Kelly in Context: A Cognitive Theory of Personality
Simply put, Kelly’s personal construct theory represents the culmination of the shift from animalistic behaviorism to humanistic cognition. In American psychology, behaviorism was a powerful force, and began with the very traditional approach of theorists such as John B. Watson and B. F. Skinner. Alongside the experimental behaviorists were the learning theorists, such as Clark Hull. As Dollard and Miller tried to find some common ground between psychodynamic theory and traditional learning approaches, they were inevitably led to consider the role of social factors in human learning. Bandura, Rotter, and Mischel built on the legacy of Dollard and Miller, but added to it the active role of cognition in the human species. Finally, Kelly moved to a purely cognitive description of how individuals become who they are.
However, we must address an important caveat. Just as Skinner’s radical behaviorism was an extreme position of ignoring cognitive processes, perhaps Kelly’s position is equally extreme for attributing significant cognitive processing to all aspects of personality and personality development. Although the man-the-scientist concept may hold a certain curious appeal for some, who doesn’t sometimes knowingly try acting in different ways to see what effect it has on others? Likewise, who isn’t attracted to a theory that says we desire the ability to both predict and control the events in our lives? However, as Kelly the therapist was keenly aware, many people cannot predict or control the events surrounding them. Is this always the result of failed construct systems, or is it possible that sometimes we just aren’t thinking? Regardless of the answer, Kelly is the recognized leader of a significant development in the field of personality, a development that contributed to the highly regarded cognitive therapies of Ellis and Beck.
It is also interesting to note that the basis for his theory of constructive alternativism questions the reality of the self in a manner similar to Eastern/Buddhist concepts of consciousness and self. Carl Jung was dramatically influenced by the ancient Vedic traditions of India, and Carl Rogers, the founder of humanistic psychology, was influenced by the spiritual traditions of China. And now we have Kelly, whose theory represents the culmination of behavioral-cognitive theories, sharing a fundamental similarity with Buddhist psychology. Clearly, throughout the history of personality theory, there have been important theorists who looked beyond the constraints of their own training and their own culture.
Kelly begins by questioning the role that psychologists have assigned to themselves. Psychologists consider themselves to be scientists, engaged in the systematic study of human behavior and thought. Kelly questions why we, as psychologists, don’t extend the same perspective to all people. According to Kelly, doesn’t every person seek to predict and control the course of events in their lives? Doesn’t every person have their own theories about situations in life, don’t they test their own hypotheses, and weigh the experimental evidence gained through experience?
…it is as though the psychologist were saying to himself, “I, being a psychologist, and therefore a scientist, am performing this experiment in order to improve the prediction and control of certain human phenomena; but my subject, being merely a human organism, is obviously propelled by inexorable drives welling up within him, or else he is in gluttonous pursuit of sustenance and shelter.” (pg. 5; Kelly, 1955a)
Since Kelly proposes that each individual is theorizing about and testing their own life circumstances, he suggests the term man-the-scientist for understanding how all people (including, of course, women) approach the world around them.
In trying to understand the world around us, using arguments that sound either existential or like Eastern philosophy, Kelly questions the existence of the universe. Of course it exists, he says, but so do the thoughts of each individual, and the correspondence between what people think exists and what does, in fact, exist is constantly changing. Thus, Kelly suggests that it is better to say that the world around us is existing, rather than to say it exists. Likewise, life can only be understood in the context of time, if it is to make sense. However, life is not simply the changes that occur over time. Rather, it is a relationship between living things and their environment. Kelly emphasizes the creative capacity of living things to represent their environment, as opposed to simply reacting to it. These representations are known as constructs, patterns that we create in our mind and attempt to fit over the realities of the world. Since our constructs don’t always fit with reality, we are constantly modifying them, as well as trying to increase our repertoire of constructs. Over time, we test our constructs for the ability to predict what will happen in our lives. With sufficient time and experience, and if we are willing to learn from our mistakes, we can evaluate all of our interpretations of the world in which we live (Kelly, 1955a).
Kelly believes that all of our present interpretations of the environment are open to revision or replacement; there are always alternative constructs that may help us deal with new or difficult situations. It is this philosophical position that Kelly refers to as constructive alternativism. It is important to keep in mind, of course, that not just any alternative will work in a given situation. Therefore, each potential alternative construct must be evaluated in terms of its specific predictive efficiency, as well as in terms of overall predictive efficiency of the system it would become part of, if that alternative construct were adopted (Kelly, 1955a).
Discussion Question: According to Kelly, it is more important to know what a person might have done, and he believed that people act as scientists, testing their constructs in order to become better at predicting and controlling their lives. Can you think of situations in which someone did what you expected, but you really wanted to know what they had thought about doing as alternatives?
Basic Theory of Personal Constructs
Personal construct theory begins with a fundamental postulate, which is then elaborated with eleven corollaries. The fundamental postulate states that “a person’s processes are psychologically channelized by the ways in which he anticipates events” (Kelly, 1955a). The carefully chosen words in this postulate define the nature of personal construct theory. The words person and he emphasize the individuality of this theory, the unique nature of each person’s constructs. Each person is then recognized as a process. The mind does not stop and start, simply reacting to stimuli, but rather it is constantly in motion, constantly experimenting with constructs. These processes operate through a network of pathways, or channels, according to the devices, or ways, a person constructs in order to achieve their goals. Since these processes, ways, and channels have not been identified as specific physiological mechanisms or anatomical structures, Kelly emphasizes that this is a psychological theory. So when we discuss this mechanism we are not necessarily addressing neuroscience on one hand or sociology on the other hand, we are working within the constraints of the field of psychology. We then have anticipation, the “push and pull of the psychology of personal constructs” (Kelly, 1955a). Being man-the-scientist, each of us seeks to predict the future and choose our actions accordingly. Finally, we have real-life events. Kelly was always very practical about both his personality theory and his approach to psychotherapy. Thus, the psychology of personal constructs is not an ethereal theory. Psychological processes, according to Kelly, are tied down to reality, and anticipation is carried forward in order to better represent future reality. Having established the fundamental postulate, Kelly then described eleven corollaries, or propositions, which both follow from the postulate and amplify his system by elaborating on the fundamental idea (Kelly, 1955a).
Construction Corollary: A person anticipates events by construing their replications. Construing refers to placing an interpretation upon an event. Since a new event will not occur exactly as a past event, our anticipation involves interpreting what the new event will be like. Kelly uses the example of a day. Today is not the same as yesterday, tomorrow will not be the same as today, but each day follows something of a similar pattern. Thus, our anticipation of tomorrow involves constructs based on both the similarities and differences between days we have experienced in the past. It is important to note that this process is not the same as cognition, it is not simply thinking about tomorrow. Much of this process is preverbal, or unconscious, and in that sense occurs automatically.
Individuality Corollary: Persons differ from each other in their construction of events. No matter how closely associated two people are, they cannot play exactly the same role in any situation. Therefore, they will interpret events differently. Although Kelly acknowledges that people often share similar experiences, particularly as they attend to the experiences of others in the same or similar situations, this corollary emphasizes the unique, subjective nature of interpreting and anticipating events.
Organization Corollary: Each person characteristically evolves, for his convenience in anticipating events, a construction system embracing ordinal relationships between constructs. When faced with conflict, there may be solutions that contradict one another. Thus, the constructs we develop may contradict each other. Kelly suggested that we develop our constructs in a systematic and organized way, with some constructs being ranked more highly than others. For example, some constructs may be good vs. bad, or stupid vs. intelligent. A stupid construct might work in a given solution, but an intelligent one would probably be preferred. For instance, suppose you have an electric garage door opener, and the power is out. You could put your car in the garage by driving through the garage door. However, it might be preferable to get out of the car, go into the garage through the house or side door, and then disconnect the garage door from the opener and open it by hand.
Dichotomy Corollary: A person’s construction system is composed of a finite number of dichotomous constructs. Every construct has both positive and negative aspects. In the example used above, both ways of putting your car in the garage have advantages and disadvantage. Driving through the garage door is quick and easy in the short term, but results in needing a new garage door. Getting out of the car and using another entrance takes more time and effort, and may be unpleasant in a bad storm, but it protects your property (and saves time and money in the long run). The essential nature of contrast was eloquently described some 2,600 years ago by Lao Tsu:
Heaven all can see beauty as beauty only because there is ugliness.
All can know good as good only because there is evil.
Therefore having and not having arise together.
Difficult and easy complement each other.
Long and short contrast each other;
High and low rest upon each other;
Voice and sound harmonize each other;
Front and back follow one another.
Lao Tsu, c600 B.C. (pg. 4; Lao Tsu, c600 B.C./1989)
Choice Corollary: A person chooses for himself that alternative in a dichotomized construct through which he anticipates the greater possibility for extension and definition of his system. Simply put, since each situation requires us to choose between the options we construct, Kelly believed we choose the alternative that serves us best (at least within our system of constructs, which may be different than the reality of the best choice). But what about situations in which the best choice is not so obvious? Kelly believed that the choice corollary allowed for shades of gray when a decision is not clearly a choice between black and white alternatives. He did not view this as a contradiction, but rather, he proposed that the choice becomes one between options that are more gray or less gray. Thus, we can maintain the dichotomy of the choice while still also allowing the choice itself.
Range Corollary: A construct is convenient for the anticipation of a finite range of events only. Every personal construct has a range or focus, and few, if any, are relevant to all events. As Kelly points out, the construct tall vs. short may apply well to descriptions of people, trees, and buildings. But what would we mean by tall weather, or short light? Clearly, the construct tall vs. short is limited to certain types of discrete, physical objects.
Experience Corollary: A person’s construction system varies as he successively construes the replications of events. As we apply constructs in our efforts to predict what happens in our lives, we sometimes experience unexpected outcomes. As a result, we reconstruct our constructs, and learn from our experiences. In other words, man-the-scientist is by definition a work in process, and that process is ongoing.
Modulation Corollary: The variation in a person’s construction system is limited by the permeability of the constructs within whose range of convenience the variants lie. This corollary addresses the ease with which the experience corollary can occur. Although all individuals modify the constructs that guide their anticipation of events, some constructs are modified more easily, and some people are more open to changing their perspectives (and, hence, reconstructing their constructs). This is one area where Kelly re-emphasizes the difference between psychological processes and the process of science. Scientists seek hypotheses, theories, and laws that are not likely to change. Indeed, there is a continuum from hypothesis to law based on how likely it is that a scientific observation is true. People, however, are constantly testing and retesting their constructs, and reconstructing them as necessary and appropriate. Therefore, people may act like scientists, but their psychological processes serve to facilitate the individual’s life, not the lives of others (as scientific theories and laws are meant to apply to the whole universe).
Fragmentation Corollary: A person may successively employ a variety of construction subsystems which are inferentially incompatible with each other. This corollary extends from the previous one, but with a twist. As an individual encounters unexpected events, they modify their constructs to the extent that they are able. Thus, their behavior may change slowly, or more quickly, depending on the nature of the constructs that guide their openness to change. The twist comes into play when individuals are either resisting change, or in the process of change, and it involves the dichotomy corollary. If an individual is failing to predict and control events in their life, they may choose an incompatible construct, essentially reversing the course of their behavior. One of the advantages of Kelly’s personal construct theory is that these dramatic changes in behavior can now be seen as reasonable progressions in one’s ongoing desire for predictability and control.
Commonality Corollary: To the extent that one person employs a construction of experience which is similar to that employed by another, his psychological processes are similar to those of the other person. This corollary is important for interpersonal relations. Even though two people cannot experience the same event in exactly the same way, their ability to share their experiences is facilitated by the similarity of their experiences. This raises important implications for therapists working with clients of different cultures, since they might not share similar constructs based on certain events. It also raises an important distinction between cognitive and behavioral approaches to understanding personality. In behavioral perspectives, simple stimulus-response relationships are the same for everyone who experiences them. However, in the cognitive perspective, each person necessarily experiences any event in a unique way.
Sociality Corollary: To the extent that one person construes the construction processes of another, he may play a role in a social process involving the other person. Humans are social creatures. Our ability to predict and control our lives is largely based on our ability to predict and either control or work with other people. Thus, it is important for individuals to construe to thoughts and behaviors of others, and in so doing we can each play a role in the lives of others. Kelly suggests that this provides a natural connection between personal construct theory and social psychology, as well as a connection between personal construct theory and cross-cultural psychology.
Dimensions of Transition
Since life is an ongoing process, there are regular transitions in one’s personal constructs. According to the organizational and modulation corollaries, individuals have certain preferences amongst their constructs and differences in their ability to reconstruct them. Problems in life arise when individuals find it difficult to transition from an ineffective construct, one that does not allow for predicting or controlling events, to an effective construct. According to Kelly (1955a), the major problems are seen as the psychological phenomena of threat, fear, guilt, and anxiety. Kelly defines these terms as follows:
Threat is the awareness of imminent
comprehensive change in one’s core structures.
Fear is like threat, except that, in this case, it is a new incidental construct, rather than a comprehensive construct, that seems about to take over.
Perception of one’s apparent dislodgment from his core role structure constitutes the experience of guilt.
Anxiety is the recognition that the events with which one is confronted lie outside the range of convenience of one’s construct system.
In each case, the psychological phenomenon is based on either the failure of one’s constructs to provide courses of action or a direct challenge to the system of constructs available to the individual. Given that the individual’s personal construct systems define the larger construct of self, these psychological phenomena represent a challenge to the very self experiencing them. In defense of the individual, aggressiveness is seen as the active elaboration of one’s perceptual field. In other words, aggressive individuals try to control events in ways that force decisions favorable to the individual. Similarly, hostility is viewed as the continued effort to extort validational evidence in favor of a type of social prediction which has already proved itself a failure. In this case, the individual tries to find confirmation of success following failed constructs, and this can only be done at the expense of others (Kelly, 1955a).
As people live their everyday lives, there are two typical cycles of transition, the C-P-C Cycle and the Creativity Cycle. The C-P-C Cycle involves circumspection, preemption, and control. Being circumspect refers to being wary, not taking risks. Thus, as we construe events we try to be precise in the development of our constructs. We then preempt these constructs for membership in an exclusive realm, one that best fits the event we are trying to predict and control. Finally, the first two steps have control as their natural consequence. Still, the individual must make the choice of that course of action, so Kelly suggests that the final C could just as well stand for choice as it does for control. In contrast, the Creativity Cycle begins with loose constructions, and then leads to tightened and validated constructions. What makes the Creativity Cycle meaningful is the individual’s ability to quickly experiment with various constructs and then seize upon the most promising, which is then tightened up and tested. Since much of this process is preverbal, the thought processes of creative individuals may not be apparent to others. According to Kelly, although individuals who begin with tight constructions might be productive, they cannot be creative. Creativity requires beginning with loose constructions (Kelly, 1955a). The value of creativity is not simply to be found as a distinction between the types of cycles experienced by individuals in their daily lives. Creativity is an important component of well-being, and a common topic in books on positive psychology and human strengths and virtues (Aspinwall & Staudinger, 2003; Cloninger, 2004; Compton, 2005; Peterson & Seligman, 2004; Snyder & Lopez, 2005). Indeed, Carl Rogers identified creativity as a significant aspect of the personality of a fully functioning person (Rogers, 1961).
Discussion Question: Many psychologists, including Kelly and Carl Rogers, consider creativity to be an essential aspect of healthy psychological development. Have you ever entered into an unfamiliar situation and tried to be creative in how you handled it? Was it difficult to set aside preconceived notions about how to act, or do you find it easy to try different things in new situations?
The Role of the Psychotherapist
Kelly was first and foremost a clinical psychologist, and his writings are full of practical examples related to clinical work. Theories are of little value unless they are rooted in the values of the psychologists using them. Kelly considered this to be particularly true of clinical psychologists, since they are routinely dealing with clients (Kelly, 1955b). Kelly believed that the role of the psychotherapist involves not only the training and perspectives of the therapist, but also a need to understand the client, and essential ethical considerations:
The role of the psychotherapist involves keen alertness to what the client expects from psychotherapy and the initial acceptance of a wide variety of client misperceptions of what psychotherapy is…it involves certain ethical obligations that transcend mere legal status. (pg. 618; Kelly, 1955b)
In his typically practical style, Kelly provides lengthy lists of what psychotherapy means to the client, the client’s conceptualization of the therapist, the clinician’s conceptualization of their role, and basic approaches to revising the client’s constructs. At the beginning of therapy, it is unlikely that the client has a good concept of what therapy is and what it can accomplish. Nonetheless, the client has some construction of what will take place in therapy. The complaint presented by the client says something about what he or she thinks therapy can accomplish, and some see therapy as an end in itself. However, the reality is that therapy is a means to an end, and that end should be generating movement forward on the part of the client. In contrast, some clients are so ready for change that the therapist must be cautious in interpreting the client’s state of mind (Kelly, 1955b). Just as the client makes predictions about therapy, they will also have an initial conceptualization of the therapist. They may construe the therapist as a parent, an absolver of guilt, a companion, or even a threat. Hopefully, according to Kelly, the client may construe the therapist as a representative of reality. In this case, the client may feel free to experiment with his or her constructs without fear of failure. Most importantly, how the client construes the therapist will have a dramatic effect on their relationship:
From the client’s conceptualization of psychotherapy comes the role he expects to play and the role he expects the therapist to play…He may be bitterly disappointed in the therapist’s enactment of the expected role. He may stretch his perceptions of the therapist in order to construe him in the manner he expected to construe him rather than in the manner the therapist seeks to be construed….The client may then feel lost and insecure in the psychotherapeutic relationship. (pg. 575; Kelly, 1955b)
As the client is engaging in these processes, the clinician is also conceptualizing their own role. Overall, the goal of any therapist should be to assist in the continuous reconstruction of the client’s construct system, and the changes that take place in therapy should set the stage for continued reconstruction after therapy has been discontinued. Initially, the therapist may rely on a variety of techniques to accomplish superficial reconstructions. The therapist needs to be patient, and initially must accept the client’s construct systems as they are. The latter point is quite similar to the empathy described by Carl Rogers in humanistic, client-centered therapy, and Kelly does indeed use the word “empathize” in his own writings. As therapy progresses, the therapist needs to help the client select new conceptual elements, accelerate the tempo of the client’s experience, and design and implement experiments. Finally, the therapist serves to validate the client’s experiments as they attempt to reconstruct their construct systems (Kelly, 1955b).
Psychological Assessment Within Personal Construct Theory
Kelly believed that therapy was a joint effort between the therapist and the client, and since the goal was the ongoing reconstruction of the client’s psychological systems (even after therapy), the client ultimately needs to become his own therapist. Therefore, the psychotherapeutic interview (Note: by “interview,” Kelly means what we would commonly call a therapy session) becomes an essential part of therapy. Throughout the process of the interview, the therapist makes decisions regarding the course of the interchange between the therapist and the client. Overall, the decisions made by the therapist are tailored to the specific client, but still the therapist must remain in control of the interview. This requires that the therapist plan for the interview. Those plans include how often to interview the client, how long the interviews should last, the tempo of the interview, and when to terminate the interview. Since the client continues to live their life outside of the interview room, the therapist must also consider whether special circumstances will require special interview plans (Kelly, 1955b, 1958). One of the most practical aspects of the interview is that the client can simply provide information needed by the therapist, to a point:
…there is a useful adage for clinical psychologists to follow on occasion: if you do not know what is wrong with a person, ask him; he may tell you. (pp. 322; Kelly, 1955a)
The Role Construct Repertory Test (Rep Test) was developed by Kelly in order to understand how a client’s personal constructs influence their personal-social behavior. The client begins with a Role Title List, on which they list the names of important people in their lives (see Table 10-1). The names are then grouped three at a time, and the client is asked to describe in what important way two of the three individuals are alike but different than the third person. A more organized form of the Rep Test, particularly useful for research purposes, involves creating the Repertory Grid. Once again the client is asked to identify significant people in their life. The grid provides three-person pairings that address various relational factors (family, intimate friends, conflicted relationships, authority figures, and values), and as before the client provides a construct that associates two of the people yet distinguishes them from the third. The common factor is listed as the emergent pole, the distinguishing factor is listed as the implicit pole. The Rep Test does not result in specific outcomes, so its interpretation is also subject to different methods. If the Rep Test is interpreted formally, it will provide results on the number and range of constructs present within the client’s construct systems. In the hands of an experienced and skilled examiner, information can be gleaned on the equivalence of constructs, thus providing deeper detail on the effective range of the client’s construct system. As more information is obtained from the Rep Test, the better able the therapist will be to guide the therapeutic process (Kelly, 1955a).
Fixed-role therapy is a technique derived from personal construct theory. First, the client prepares a self-characterization sketch, a technique in which the client is asked to write a character sketch about themselves as if they were the principal character in a play, but written as if by a friend who knows the client well. Using information from the self-characterization sketch, as well as from interviews and perhaps the Rep Test, the therapist then writes a fixed-role sketch. The client is asked to act out the fixed-role sketch over a period of weeks. Initially, Kelly and his colleagues emphasized minor changes in the client’s construct systems. However, they later found that it is often easier for a client to play out roles that are the opposite of their usual constructs, rather than making only minor changes in their behavior. Over time, it is expected that the client will learn that the new construct systems are more predictive than their old construct systems, and the fixed-role therapy will establish an ongoing process of reconstruction within the client (Kelly, 1955a).
Table 12.1: The Role Title List Used for the
Personal Construct Repertory Test
1. A teacher you liked. (Or the teacher of a subject you liked.)
2. A teach you disliked. (Or the teacher of a subject you disliked.)
3. Your wife or present girl friend.
3a. (for women) Your husband or present boy friend.
4. An employer, supervisor, or officer under whom you worked or served and whom
you found hard to get along with. (Or someone under whom you worked in a
situation you did not like.)
5. An employer, supervisor, or officer under whom you worked or served and whom
you liked. (Or someone under whom you worked in a situation you liked.)
6. Your mother. (Or the person who has played the part of a mother in your life.)
7. Your father. (Or the person who has played the part of a father in your life.)
8. Your brother nearest your age. (Or the person who has been most like a brother.)
9. Your sister nearest your age. (Or the person who has been most like a sister.)
10. A person with whom you have worked who was easy to get along with.
11. A person with whom you have worked who was hard to understand.
12. A neighbor with whom you get along well.
13. A neighbor whom you find hard to understand.
14. A boy you got along well with when you were in high school. (Or when you were 16.)
15. A girl you got along well with when you were in high school. (Or when you were 16.)
16. A boy you did not like when you were in high school. (Or when you were 16.)
17. A girl you did not like when you were in high school. (Or when you were 16.)
18. A person of your own sex whom you would enjoy having as a companion on a trip.
19. A person of your own sex whom you would dislike having as a companion on a trip.
20. A person with whom you have been closely associated recently who appears to dislike you.
21. The person whom you would most like to be of help to. (Or whom you feel most sorry for.)
22. The most intelligent person whom you know personally.
23. The most successful person whom you know personally.
24. The most interesting person whom you know personally.
Discussion Question: Kelly’s fixed-role therapy requires the client to write a script for how they want to live their life. He found that sometimes it was easier for his clients to act out the opposite of their typical behavior. Would you find it easier to make minor changes in your behavior, or easier to make dramatic changes?
Across Cultures: Understanding
Culture’s Effects on
Cognitive Style as a Prerequisite for Effective Cognitive-Behavioral Therapy
An essential element of all cognitive therapies is the desire to identify and challenge a client’s underlying dysfunctional cognitions, whether they are mistaken beliefs, schemas, automatic thoughts, cognitive distortions, whatever the case may be. To do so, requires that the therapist knows when cognitions are dysfunctional, and to some extent, what would be a reasonable cognition in the client’s personal situation. While it may seem obvious that any psychologically healthy person, particularly a trained therapist, would be able to recognize the difference between functional and dysfunctional thoughts, feelings, and behaviors, this assumes that the therapist and the client come from similar environments. This may very well NOT be the case when the client and the therapist come from dramatically different cultures. Furthermore, as G. Morris Carstairs noted regarding psychiatric interviews (1961), it makes a significant difference whether it is the therapist or the client who is outside of their familiar culture. For example, when a psychologist conducts research in a foreign country, particularly in small towns or villages, local people may simply fear and avoid strangers.
Kelly discussed culture at length in The Psychology of Personal Constructs (Kelly, 1955a,b). Both the commonality corollary and the sociality corollary are directly influenced by our understanding of culture. We, and by “we” I mean to include therapists, tend to expect that people from similar cultures have experienced basically similar upbringings and environments. We also tend to believe that people from a given culture share their expectations regarding the behavior of others from that culture. Thus, in order for a therapist to gain access to the personal constructs of their client, it is important for the therapist to learn as much as possible about the client’s cultural heritage. Failure to do so may interfere with the therapist’s ability to understand some of the client’s disruptive anxieties about either therapy itself or their life in general. Indeed, Kelly shares an example in which a White therapist (whom Kelly was supervising) found it difficult to help a Black client, because the Black client was overly anxious about discussing racially charged feelings regarding interracial sexual relationships. Since the client had discussed sexual issues before, the White therapist did not readily recognize the discomfort with which the Black client addressed his attraction to White women (remember, this was in the 1950s!).
Kelly goes on to discuss cultural differences in mannerisms, language, expectations regarding mental illness, the influence of religion, and how a therapist might go about learning more about a client’s cultural experiences. He does caution, however, that one should not attribute too much value to the influence of culture:
…It is important that the clinician be aware of cultural variations. Yet, from our theoretical view, we look upon the “influence” of culture in the same way as we look upon other events. The client is not merely the product of his culture, but it has undoubtedly provided him with much evidence of what is “true” and much of the data which his personal construct system has had to keep in systematic order. (pg. 688; Kelly, 1955b)
For example, it is often considered the mark of a sophisticated clinician that he considers all of his clients in terms of the culture groups to which they belong. Yet, in the final analysis, a client who is to be genuinely understood should never be confined to the stereotype of his culture. (pg. 833; Kelly, 1955b)
Albert Ellis and Aaron Beck, originators of the best known cognitive-behavioral therapies (see Beck & Weishaar, 1995; Ellis, 1995), also discussed cultural influences, though not as extensively as Kelly had. Ellis emphasized that each individual develops a belief system which helps them make judgments and evaluate situations. Although each person’s belief system is unique, they share many beliefs with other members of their society and/or culture. Perhaps more importantly, different cultures can have very different belief systems. To complicate the situation even further, cultural beliefs can change, either due to gradual evolution of the culture or in a more dramatic fashion when an influential thinker or leader offers a different perspective on life (Ellis, 1977). Beck has discussed how culturally-determined schemas can be so fundamental that they contribute to how and who we both love and hate (Beck, 1988, 1999).
Today, studies on the relationship between culture and cognition continue, both in clinical and non-clinical settings. There are at least two handbooks focusing on cross-cultural and multicultural factors in personality assessment (Dana, 2000; Suzuki, Ponterotto, & Meller, 2001). According to Suzuki, et al. (2001), these handbooks are necessary due to “the growing number of racial and ethnic minorities in the United States and in recognition of the multitude of variables that affect performance on cognitive and personality tests…” As assessment transitions to therapy, it becomes quite a challenge for any therapist to be familiar with the wide variety of cultures in America. Axelson (1999) has identified six basic cultural groups in America: native Americans, Anglo-Americans, European ethnic Americans, African Americans, Hispanic Americans, and Asian Americans. This list obviously does not include the many immigrants living in this country who are not considered to be American. When faced with such cross-cultural challenges, the essential skills for a therapist include careful and active listening, genuine verbal and nonverbal responses that indicate successful communication, being honest about what you do not understand, respecting and caring about the client, and being patient and optimistic (Axelson, 1999).
Additional studies have suggested that cultural knowledge influences the interpretation of stimuli in a dynamic, constructivist fashion (Hong, Morris, Chiu, & Benet-Martinez, 2000), that these processes occur automatically (Bargh & Williams, 2006), and that experiencing a wider variety of cultures in one’s education may actually lead to more complex cognitive processing (Antonio, Chang, Hakuta, Kenny, Levin, & Milem, 2004). When considering fundamental cultural differences, what some consider the core values that distinguish amongst cultures, most psychology students are familiar with the distinction between individualistic and collectivistic cultures (cultures in which one favors one’s own goals as compared to subordinating one’s own goals in favor of group goals). However, Laungani (1999) suggests that there are three other common dimensions: free will vs. determinism, materialism vs. spiritualism, and cognitivism vs. emotionalism. According to Laungani, Western cultures tend to be work- and activity-centered. Thus, they operate in a cognitive mode that emphasizes rational, logical, and controlled thought and behavior. Non-Western cultures, in contrast, tend to be relationship-centered, operating in an emotional mode. Public displays of feelings and emotions, both positive and negative, are not frowned upon (Laungani, 1999). These core values carry over into cognitive styles. For example, the cognitive style prevalent in Africa tends toward synthesis, as opposed to analysis. Africans tend to integrate their experiences into an inclusive whole, and they view such tendencies as more natural than the typical Western alternative (Okeke, Draguns, Sheku, & Allen, 1999). Thus, one can imagine a therapeutic situation in which the client resists analyzing their problems, and the therapist considers that resistance to be a specific problem unique to the client. Any subsequent attempts by the therapist to break down that resistance would be flawed, since the therapist has not understood the underlying cognitive style of the client. The failure of therapists to properly address the significance of cultural factors in therapy, regardless of whether or not their failure was unintentional, has been described as cultural malpractice (Iijima Hall, 1997).
Cognitive-Behavioral Therapy and Acceptance Therapy
Albert Ellis and Aaron Beck are not known as personality theorists, but both are well-known therapists and prolific authors. Their unique approaches to therapy are, of course, based on their theoretical perspectives, each of which emphasizes cognitive processes. Thus, we will take a brief look at how they have applied cognitive aspects of personality theory to the treatment of psychological disorders.
Pretzer and Beck (2005) have suggested that cognitive therapies are truly integrative approaches that treat the individual within a phenomenological perspective. Beck was trained as psychoanalyst, and began examining his patients’ thought processes carefully in an attempt to prove that Freud was right about depression being the result of anger turned inward. However, Beck instead discovered that his patient’s thoughts focused more on themes such as despair and defeat, and that their appraisals of situations in life and their consistently negative biases in processing information were better predictors of their mood and behavior. Thus, Beck began to develop a cognitive approach to working with his patients. At the same time Ellis was developing rational-emotive therapy, and the two theories have influenced each other in many ways (Pretzer & Beck, 2005). In addition, cognitive therapy has been influenced by many other developments in the field of psychology, including the work of Freud, Adler, Horney, Rogers, Bandura, and, of course, Kelly. The integration of these various approaches, in order to truly understand the individual, requires the therapist to work actively with the client:
…The idea of “collaborative empiricism” is central to the practice of cognitive therapy. In the course of therapy, the cognitive therapist works with his or her client to collect detailed information regarding the specific thoughts, feelings, and actions that occur in problem situations. These observations are used as a basis for developing an individualized understanding of the client which provides a basis for strategic intervention…For the cognitive therapist to intervene effectively, he or she must endeavor both to understand the individual’s subjective experience and to perceive objective reality accurately. (pp. 46-47; Pretzer & Beck, 2005)
More recent developments in cognitive therapy have focused on accepting the circumstances of one’s life, doing so not as an excuse, but in order to facilitate moving forward from that point. Acceptance and Commitment Therapy (ACT) acknowledges the presence of suffering in human life, and focuses on using mindfulness to re-orient one’s relational framework to the circumstances of one’s life (Eifert & Forsyth, 2005; Hayes & Smith, 2005; Hayes, Strosahl, & Wilson, 1999). ACT has many elements in common with the traditional practice of Buddhist mindfulness, an approach that is taken directly in Radical Acceptance (Brach, 2003)
Brief Biographies of Albert Ellis and Aaron Beck
Albert Ellis was born in 1913 in Pittsburgh, Pennsylvania. When he was 4 years old his family moved to New York City, and Ellis has remained there ever since. Although Ellis considered his childhood to have had no significant effect on his subsequent career in psychology, there were some rather dramatic factors that influenced the person he became. His father was a traveling salesman who was seldom home, and when he was home he paid little attention to his children. After his parents were divorced, Ellis seldom saw his father again. His mother wasn’t much more attentive, doing very little for the children, and often leaving them home alone. Ellis later wrote: “As for my nice Jewish mother, a hell of a lot of help she was!” (cited in Yankura & Dryden, 1994). Ellis was also very sick following tonsillitis and a strep infection. He needed emergency surgery, and then developed nephritis. Over the next 2 years, from 5 to 7 years old, he was hospitalized eight times, once for 10 months. Yet his parents remained uncaring, and he would sometimes go weeks without anyone from the family visiting him in the hospital. The illness kept him from playing sports or other games even when he was home from the hospital. Perhaps as a result of all of these circumstances, or perhaps because of his temperament, Ellis was painfully shy. He dreaded public activities, such as when he won an award for his excellent academic work, and he avoided making social overtures toward any girl he had a crush on (Yankura & Dryden, 1994).
Surprisingly, Ellis grew strong from these experiences. He thrived on his independence and autonomy, and turned his attention toward his schoolwork. He obtained praise from adults other than his parents, and at one point became something of a leader amongst the children in the hospital. Although his shyness plagued him for many years, he developed a strong sense of self-esteem based on his success in academics. Most importantly, he developed a sense of choosing to overcome his adverse childhood. He did not become a strong-willed individual because of his bad childhood, for example he describes his sister as never really being happy, but in spite of it, due largely to being born with an innate capacity for rational thinking (Yankura & Dryden, 1994).
Much like B. F. Skinner, Ellis hoped to become a writer. Having finished high school at the age of 16, he decided to attend business school at the City College of New York so he might make enough money to support his writing career. However, the Great Depression was just beginning, so there was little opportunity for a young man to make money in business. Nonetheless, he wrote a great deal. He wrote a 500,000-word autobiographical novel. By the age of 28 he had written twenty full-length novels, plays, and books of poetry. None of them were published. He also wrote numerous non-fiction works on sex, philosophy, and politics. None of them were published. However, his research on the topics of sex, love, and marriage made him a popular source of advice amongst his friends. And so he decided to pursue professional training in psychology (Yankura & Dryden, 1994).
Ellis began his studies in the psychology program at Columbia University, and then transferred to the clinical psychology program at Teachers College of Columbia University, receiving a Ph.D. in clinical psychology in 1947. That year he also began training as a psychoanalyst at the Karen Horney Institute for Psychoanalysis. His training analyst was Dr. Charles Hulbeck, who had been analyzed by Hermann Rorschach. One of the personal issues Ellis addressed during his training analysis was whether or not to marry the women he had begun dating. He eventually decided not to marry her (he was later married twice, one marriage ended in annulment, the other in divorce). Ellis was successful as a psychoanalyst, but many patients couldn’t afford to come as often as was recommended in traditional psychoanalytic theory. Curiously, Ellis noticed that patients who came less often seemed to fare better in therapy, especially when the constraints of limited time caused Ellis to be more proactive in therapy. He pursued this active-directive approach to therapy, and by the mid-1950s he had developed rational emotive behavior therapy to the point where he published his first articles and began describing the technique at professional conferences (Yankura & Dryden, 1994).
Ellis devoted the rest of his career to establishing rational emotive behavior therapy as a significant force in psychotherapy. In 1959 he established the Institute for Rational Living, and by the 1980s there were similar institutes in Australia, Britain, Canada, Germany, Israel, Italy, Mexico, and the Netherlands. He has written over 75 books, beginning with How to Live with a Neurotic (Ellis, 1957), hundreds of articles, and he has received many distinguished awards. After 60 years as a psychotherapist, marriage and family counselor, and sex therapist, Ellis has been honored as a fellow of five major associations. He was recognized with the Humanist of the Year Award by the American Humanist Association, the Distinguished Psychologist Award of the Academy of Psychologists in Marital and Family Therapy, the Distinguished Practitioner Award of the American Association of Sex Educators, Counselors and Therapists, and the American Psychological Association has recognized him for Distinguished Professional Contributions to Knowledge. In a 1991 survey ranking the “Most Influential Psychotherapist,” Canadian psychologists ranked Ellis #1, whereas American psychologists ranked him second to Carl Rogers, but ahead of third-place Sigmund Freud (Ellis, 1994, 2005; Yankura & Dryden, 1994)!
In most ways, Aaron Beck’s childhood couldn’t have been more different than that of Ellis. Born in 1921, he was the youngest child of loving and supportive parents. His parents were particularly supportive of education: his brother Irving became a physician, and his brother Maurice entered social work after earning a Master’s degree in psychology (the other two children had died in childhood, his only sister dying in the worldwide influenza epidemic of 1919). Like Ellis, however, Beck was extremely ill as a child. When he was seven years old, Beck broke his arm at a playground. An infection set in, which then developed into septicemia (a generalized blood infection). At the time, septicemia was 90 percent fatal, and his brother Irving overheard the doctor tell their mother that Beck would die. Although he obviously survived, he missed so much school that he had to be held back a year. As often happens when young children are held back in school, the effect on his self-esteem was devastating, and Beck came to believe that he was stupid and inept (Weishaar, 1993; for more information on the negative effects of grade retention visit the National Association of School Psychologists’ website at www.nasponline.org).
However, with the help of his brothers, Beck was able to catch up to and eventually surpass his classmates, graduating first in his high school class. Along the way he belonged to the Audubon Society, worked as a camp counselor, became the youngest Eagle Scout in his Boy Scout troop, and was editor of the high school newspaper. He followed his brothers to Brown University, but was unsure of a career path. He majored in English and Political Science, but he took a wide variety of courses, eventually taking the courses necessary to go on to medical school. He graduated magna cum laude, Phi Beta Kappa, and won awards for oratory and essay writing. Despite his dramatic successes, Beck suffered a great deal of anxiety, particularly a blood/injury phobia that most likely resulted from his frightening experiences related to the emergency surgery necessary when he broke his arm. Having been accepted to the Yale School of Medicine, his surgery rotation was very difficult in light of his fear of blood. However, he worked through his fears cognitively (an obvious foreshadowing of the work that would make him famous), and successfully completed his medical degree (Weishaar, 1993).
Beck never intended to study psychiatry, and thought little of psychoanalysis. However, having graduated in 1946, there were many veterans returning from World War II. In 1949, he began a residency in neurology at a veteran’s administration hospital in Massachusetts. Due to a pressing need for psychiatrists, the director of the program began requiring everyone to complete a rotation is psychiatry. The psychiatry program at the hospital was primarily influenced by the Boston Psychoanalytic Institute, and Beck protested that psychoanalytic formulations seemed far-fetched, but he eventually decided to stay in psychiatry and to study psychoanalysis in greater detail. He first studied psychoanalysis at the Austin Riggs Center in Massachusetts, where one of his supervisors was Erik Erikson. After completing his training in psychiatry, he joined the faculty of the University of Pennsylvania Medical School (in 1954), where he has remained ever since. As he began his research career, Beck intended to confirm Freud’s hypothesis that depression was the result of hostility turned inward. However, he began to recognize that his patients were greatly influenced by underlying patterns of cognition, the so-called automatic thoughts that are so well-known today. About this same time, Beck learned of Kelly’s work on personal constructs (which Beck later referred to as schemas). As a result of these ideas and experiences coming together, Beck’s own cognitive theory began to take shape. Then, in 1963, Ellis read an article written by Beck. Ellis sent copies of his own work to Beck, and reprinted Beck’s article in the journal Rational Living. Beck then invited Ellis to speak to the psychiatry residents at Penn, and from that point forward the two maintained close contact. Beck has credited Ellis as being an excellent spokesperson for cognitive approaches to psychotherapy (Weishaar, 1993).
During his career, Beck has received many awards, including the Distinguished Scientific Award for the Applications of Psychology from the American Psychological Association. He has also received major awards from the American Psychiatric Association, the American Psychopathological Association, and the American Association of Suicidology. He received an honorary doctorate in medical science from his alma mater, Brown University, in 1987 he was elected a Fellow of the Royal College of Psychiatrists (England), and he is a senior member of the Institute of Medicine. Perhaps the most meaningful tribute, however, is that his daughter, Dr. Judith Beck, has followed in his footsteps. She is currently the Director of the Beck Institute for Cognitive Therapy and Research, and a Clinical Associate Professor at the University of Pennsylvania. She has written a number of books on cognitive therapy and, with her father, developed the Beck Youth Inventories (for more information visit the website for the Beck Institute for Cognitive Therapy and Research at www.beckinstitute.org).
Placing Ellis and Beck in Context: Cognitive Therapy
In one sense, Ellis and Beck do not belong in a book about personality theory. They are not known for their theoretical contributions to our understanding of personality development. In another sense, they are among the most important theorists covered, since the practical application of cognitive theories to psychotherapy has had a dramatic influence on the effectiveness of psychotherapy in treating psychological disorders. Remember that Freud, as well as most of the other well-known psychodynamic theorists, began conducting therapy first and later developed theoretical perspectives which helped to explain what they saw in their patients and what worked in therapy. Similarly, Ellis and Beck focused on the development of their therapeutic approaches, and to a large extent their theoretical perspective is inferred from the techniques they use in therapy.
In addition, one could argue that the cognitive therapies of Ellis and Beck stand at the pinnacle of the behavioral and cognitive theories of personality that have been so influential in American psychology. As evidence of their significance, Beck received an Albert Lasker Clinical Medical Research Award in 2006. Often called the American Nobel Prize (some seventy recipients have gone on to win a Nobel Prize), in the 60 years that the Lasker prizes have been awarded, Beck is the first psychotherapist to be honored. This award is a testament both to the respect that cognitive psychotherapy has earned in the medical community and to Beck for the honor he has earned amongst many ground-breaking psychotherapists.
Although cognitive therapies may seem highly specialized, both Ellis and Beck drew upon many different areas of psychology and psychiatry, as well as Eastern philosophies, while developing their techniques. Their psychoanalytic training exposed them to the directive approach of Adler and to Horney’s emphasis on the (which can be viewed as a neurotic belief or a type of automatic thought). In addition, they cited theorists, authors, and spiritual leaders such as Bandura, Frankl, Rogers, Piaget, the Dalai Lama, D. T. Suzuki, Lao Tsu, Jesus of Nazareth, and many others. The range of ideas that Ellis and Beck synthesized into a cohesive and direct approach to psychotherapy is unparalleled in the fields of psychology and psychiatry.
Rational Emotive Behavior Therapy
In order to understand Ellis’ perspective on therapy, one must first understand his perspective on the basis of psychological disturbances, whether they are minor problems with personal adjustment or more serious forms of mental illness. Individuals with problems typically have a long history related to the disorder. Using the same example as Ellis (1957), suppose a woman is chronically depressed because she has been rejected by men she really liked and with whom she wanted to have long-term relationships. She understandably concludes that the activating event of being rejected leads to the consequence of being depressed. However, this conclusion is wrong! According to Ellis, it is not the rejection that causes her depression, it is the belief system that arises within her, particularly irrational beliefs, that cause her depression. For example, if she rationally believed that it was unfortunate that someone she liked rejected her, or that it was frustrating that she was rejected, she might not become depressed. However, if she irrationally believes that it is awful that she has been rejected, or that she should have been more beautiful so that he wouldn’t have rejected her, then she is quite likely to become depressed. This is what Ellis referred to as the A-B-C’s of emotional disturbance or self-defeating behaviors and attitudes. A refers to the activating event (being rejected), B refers to the person’s beliefs(this is awful, I’m not pretty), and C is the consequence of the beliefs: depression. The basis for therapy in such situations can be found by extending the A-B-C’s to the D-E’s: disputing (D) the irrational beliefs, which hopefully leads to the cognitive effect (E - effective new philosophies, emotions, and behaviors) of disrupting the self-defeating patterns of behavior (Ellis, 1957, 1973, 1996). More recently, Ellis has proposed one more letter for his ABC theory of personality, the letter G for goals (*note: there is no “F”). Goals consist of a person’s purposes, values, standards, and hopes. When these goals are thwarted by an activating event, the person can respond by choosing healthy or unhealthy alternatives, and the nature of that choice is based on one’s beliefs (Ellis, 1994). Ellis considered the ABC theory to be so straightforward that it could prove helpful to anyone.
When an individual has become trapped by unhealthy belief systems and the corresponding self-defeating behavior patterns that accompany them, the potential need for psychotherapy arises. The therapy that Ellis developed has come to be known as rational emotive behavior therapy, or REBT (the name went through several permutations over Ellis’ career, and he finally settled on REBT). The primary task of the therapist using REBT is to challenge the client’s irrational beliefs and, in so doing, to help the client change their belief systems. In essence, when the client believes that it would be catastrophic for a certain negative outcome to occur, the therapist tries to help them by disputing the irrational belief with questions such as: “Why would a certain outcome be catastrophic?” While trying to dispute the irrational beliefs, the therapist also searches for underlying philosophies that support the irrational belief system, philosophies that can then also be disputed. In addition to the cognitive aspect of REBT, the therapist often encourages the client to act against their irrational fears. If the client is willing, they have the opportunity to experience anxiety-ridden situations without the catastrophic consequences they have feared (although the help of the therapist may prove necessary along the way). Throughout this process, REBT does not intend to ignore the person’s feelings. However, when a client is suffering from unhealthy and self-defeating feelings, such as anxiety, depression, or anger, REBT can help to minimize those unhealthy feelings. In addition, REBT encourages healthy, positive emotions, and recognizes that sometimes a strong negative response, such as sadness or grief, to a tragic activating event may be healthy or constructive. When utilized effectively, REBT offered what Ellis believed was a better, deeper, and more enduring therapy, which could achieve those results in a fairly brief amount of time (Ellis, 1962, 1973, 1994, 1995, 1996). Ellis also believed that REBT was applicable to a wider range of clients than any other psychotherapy:
RET [later known as REBT], on the contrary, seems to be almost the only major kind of psychotherapy (aside, perhaps, from Zen Buddhism, if this is conceptualized as psychotherapy…) that holds that the individual does not need any trait, characteristic, achievement, purpose, or social approval in order to accept himself. In fact, he does not have to rate himself, esteem himself, or have any self-measurement or self-concept whatever. (pg. 65; Ellis, 1973)
First and foremost, Ellis focused on practical applications of psychotherapy, and he considered his approach to be humanistic in its emphasis on the whole person. He acknowledged that REBT shared important elements with the approaches of other classic theorists who had emphasized the value of individuals, including Alfred Adler, Viktor Frankl, Rollo May, Carl Rogers, Abraham Maslow, and Karen Horney (Ellis, 1973, 1995). Ellis’ discussion of the practice of REBT seems to focus on what Horney addressed in her concepts of neurotic needs and the tyranny of the should. Taken together, the desire to focus on practical applications and helping individuals has led to a wide variety of self-help books based on REBT (Yankura & Dryden, 1994). Naturally, this list includes many books by Ellis himself, including titles such as How to Live With a Neurotic (Ellis, 1957), A New Guide to Rational Living (Ellis & Harper, 1975), How to Live With - and Without - Anger (Ellis, 1977), How to Cope With a Fatal Illness (Ellis & Abrams, 1994), How to Keep People from Pushing Your Buttons (Ellis & Lange, 1994), How to Control Your Anxiety Before It Controls You (Ellis, 1998), and Sex Without Guilt in the 21st Century (Ellis, 2003). REBT has also been applied to a wide variety of other problems that have been covered in Ellis’ books, such as marriage counseling, personality disorders, depression, and even schizophrenia, and REBT has proved successful in both individual and group settings (Ellis, 1962, 1973, 2001; Ellis & Dryden, 1987).
Discussion Question: Rational emotive behavior therapy is based on the ABC theory of personality. Can you think of situations in which activating events led you to specific consequences, even though your beliefs, if you thought about them enough, were the real reason for the consequence you experienced?
Ellis, as well as other therapists using REBT, has also addressed addictive disorders, including alcoholism (Ellis, 2001; Ellis, McInerney, DiGuiseppe, & Yeager, 1988; Trimpey, Velten, & Dain, 1993; Yeager, Yeager, & Shillingford, 1993). In the early 1990s, Rational Recovery (RR) was developed by Jack Trimpey as an alternative to the Alcoholics Anonymous (AA) approach to treating alcohol abuse. Both Ellis and Trimpey challenge the basic principles of AA: that the addict has no control over their alcohol cravings, that they must turn over control to a higher power (such as God), that they can never drink alcohol again, and that only AA works for alcoholics. Objective research simply does not support these assertions, and practitioners of REBT and RR have great faith in the ability of individuals to take control of their own lives (though they may need some help from a therapist to get on the right path). RR also does not include the strong religious overtones of AA, which may be an impediment to recovery for anyone required to attend AA meetings but who does not believe in God:
…The core of these methods is learning to recognize and dispute self-defeating thinking that RR frequently labels “the Beast” or “the addictive voice.” In addition to its treatment purposes, RR has a political purpose in advocating for people who are mandated to attend spiritual healing groups but who find that approach useless or offensive. Furthermore, RR attempts to educate professionals about available options and sensitize them to the ethical and possible legal issues involved in overriding client’s objections to spiritual healing approaches. (pg. 271; Trimpey, Velten, & Dain, 1993)
Since REBT focuses on the choices that individuals make for themselves, what role is there for religion within such a perspective? Ellis maintains that there is a significant positive correlation between devout religious beliefs and a variety of emotional disturbances. However, he has argued that the problem is not religion per se, but rather highly restrictive, dogmatic religiosity that causes problems for an individual (Ellis, 2004; also see Yankura & Dryden, 1994). Ellis studied the works of Lao Tsu (author of the Tao Te Ching), Gotama Buddha (known by most people simply as the Buddha), and the existential theologian Paul Tillich, finding helpful perspectives for working with his clients and on his own problems (Ellis, 2004). He overcame his early objections to religion and spirituality by recognizing that when one’s religious beliefs contribute to good psychological health the belief itself, regardless of whether or not God exists, is helpful. Similarly, Zen Buddhism is not actually a religion, but has significant religious overtones. Nonetheless, Ellis was impressed by the effectiveness of Zen meditation for many clients, so he incorporated various Eastern perspectives into the development of REBT.
Discussion Question: Alcoholics Anonymous has helped many people, but it doesn’t help everyone, especially those who are opposed to religiosity or are simply atheists. Nonetheless, the AA approach has become a standard recommendation in many legal jurisdictions when someone commits a crime such as drunk driving. What do you think about Rational Recovery (based on REBT) as an alternative to AA?
Is Self-Esteem a Sickness?
The heading for this section is the title of the first chapter in a fascinating book by Ellis: The Myth of Self-Esteem (Ellis, 2005). Ellis believed that self-esteem is defined by psychologists in a way that requires individuals to rate, or judge, themselves. This may work fine when everything is going well for the person, but people are not perfect. Thus, they will eventually fail at something, perhaps at many things, and they must then judge themselves as bad, or unworthy. If, however, you accept yourself as imperfect, and rate only your behaviors and thoughts, not your self, then you need not suffer from the effects of low self-esteem. In other words, Ellis advocates unconditional self-acceptance, a very old philosophy known to the Greeks, Romans, Buddhists, Daoists, and others (Ellis, 2005). Ellis considers many different approaches to the concepts of self-esteem and self-acceptance, including the perspectives of Solomon, Jesus of Nazareth, the existential philosophers Kierkegaard, Heidegger, and Sartre, Carl Rogers, the Eastern philosophers Lao Tsu, D. T. Suzuki, and the Dalai Lama, and Steven Hayes (founder of Acceptance and Commitment Therapy, see below). Ellis concludes that one must seek not only to unconditionally accept oneself, but also to unconditionally accept others and the nature of life itself. But this is not a pie-in-the-sky philosophy. Ellis recognizes that there are sad and unfortunate events in life (we are fallible, and we are mortal). He strongly recommends that we do not avoid normal sadness and regret, since these emotions provide the motivation for trying to prevent unfortunate events and for seeking new relationships. The choice is yours:
Both self-esteem and self-acceptance, then, can be had definitionally - for the asking, for the choosing. Take one or the other. Choose! Better yet, take no global rating. Choose your goals and values and rate how you experience them - well or badly. Don’t rate yourself, being, entity, personality at all. Your totality is too complex and too changing to measure. Repeatedly acknowledge that.
Now stop farting around and get on with your life! (pg. 16; Ellis, 2005)
Discussion Question: Ellis opposes the concept of self-esteem because he believes it requires a person to judge themselves. He advocates instead that we unconditionally accept ourselves, faults included. Does this make sense to you?
Beck's Cognitive Model of Depression
Having begun his research in an attempt to examine Freud’s theory on the cause of depression, Beck continued studying depression and suicide throughout his career. The reason for this continued focus was the prevalence of depression in society:
Depression is the most common psychiatric disorder treated in office practice and in outpatient clinics. Some authorities have estimated that at least 12 per cent of the adult population will have an episode of depression of sufficient clinical severity to warrant treatment. (pg. vii; Beck, 1967)
Relying on an interplay between clinical work and research, Beck proposed a cognitive model based on automatic thoughts, schemas, and cognitive distortions (Beck, 1967; Beck & Freeman, 1990; Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 1995; Pretzer & Beck, 2005). Automatic thoughts are an individual’s immediate, spontaneous appraisals of a given situation. They shape and elicit a person’s emotional and behavioral responses to that situation. Since they are automatic, they are rarely questioned. Even when they are predominantly negative, the individual accepts them as true and can be overwhelmed by constant questions and images that hurt one’s self-esteem (questions such as “Why am I such a failure,” or seeing oneself as ugly). The reason that even highly negative automatic thoughts are accepted, even when they might be objectively untrue, is that these thoughts do not arise spontaneously. Rather, they are the result of the person’s schemas. Every situation is comprised of many stimuli, and when confronted with an unfamiliar situation a person tends to conceptualize it. Although different people will conceptualize the situation differently, each individual will be consistent. These stable cognitive patterns of interpreting situations are known as schemas. An individual’s schemas then determine how they are likely to respond, automatically, to many situations.
People are also prone to a variety of cognitive distortions, which can amplify the effects of one’s schemas, thus helping to confirm maladaptive schemas even when contradictory evidence is available. Over time, Beck and his colleagues have identified a growing number of such distortions, such as: dichotomous thinking, or seeing things as only black or white, without the possibility of shades of gray; personalization, the tendency to interpret external events as being related directly to oneself; overgeneralization, the application of isolated incidents to either all or at least many other situations; and catastrophizing, treating actual or anticipated negative events as intolerable catastrophes, even though they may be relatively minor problems. Overall, these cognitive distortions lead the individual into extreme, judgmental, global interpretations of the situations they experience, which establish general schemas, which lead to automatic thoughts and feelings that support the idiosyncratic experience of the world (Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 1995; Pretzer & Beck, 2005). The goal of cognitive therapy, therefore, is to help the individual break out of this self-supporting, maladaptive pattern of cognition.
Another important aspect of the depressive syndrome is known as the cognitive triad, three cognitive patterns that cause the person to view themselves in a negative manner. First, the individual has a negative view of themselves. Primarily, the depressed individual sees themselves as defective in some psychological, moral, or physical way, and because of the presumed defects they are undesirable and worthless. Second, the depressed person has a tendency to interpret their ongoing experiences in negative ways. These negative misinterpretations persist even in the face of incompatible evidence. And finally, they tend to hold a negative view of the future. They anticipate continued difficulty, failure, emotional suffering. As a result, they lack motivation, they become paralyzed by pessimism and hopelessness. According to Beck, suicide can be viewed as an extreme attempt to escape problems that depressed individuals believe cannot be solved and the unbearable suffering that the future holds! These negative cognitive patterns are not something that the depressed person plans or has much control over, since they typically occur in the form of automatic thoughts (Beck, 1967; Beck, Rush, Shaw, & Emery, 1979; Beck & Weishaar, 1995; also see Beck, Resnick, & Lettieri, 1974).
Discussion Question: Beck described a number of common cognitive distortions, including dichotomous thinking, personalization, overgeneralization, and catastrophizing. Think about situations in your own life when you made these distortions. What sort of problems resulted from these cognitive errors, and how often do you make them?
Beck's Cognitive Therapy
Cognitive therapy, according to Beck, “is an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders” (Beck, Rush, Shaw, & Emery, 1979). With regard to depression, it is most effective after a major depression has lifted somewhat, though it can also be helpful for some patients during depression, particularly if the depression is of the reactive type (as opposed to endogenous depression; Beck, 1967). As mentioned above, the basic procedure is to help the individual break out of the trap of negative schemas, automatic thoughts, and cognitive distortions that support the client’s problem. The techniques employed are designed to identify, test the reality of, and correct the cognitive distortions and schemas that lead to dysfunctional automatic thoughts. It involves an active collaboration between the therapist and the client, such that the client learns to reduce their symptoms by thinking and acting more realistically.
Beck referred to the constant interaction between the client and the therapist as collaborative empiricism, and contrasted this approach to both psychoanalysis and client-centered therapy. His intention was to provide the client with a series of specific learning experiences that would teach the patient the following skills: (1) monitoring their own negative, automatic thoughts; (2) recognizing the connections between thought, emotion, and behavior; (3) examining evidence for and against their cognitive distortions; (4) substituting reality-based interpretations for their cognitive distortions; and (5) learning to identify and alter the dysfunctional schemas that lead to the cognitive distortions (Beck, Rush, Shaw, & Emery, 1979). The interaction with the client is not superficial, as it involves discussing the very rationale of the therapy to the patient and, ultimately, providing the client with techniques to monitor their dysfunctional thoughts on their own. The therapist teaches the client to recognize the nature of cognition, particularly the client’s dysfunctional cognitions, all with the goal of eventually neutralizing the automatic thoughts. Somewhat related to collaborative empiricism is the concept of guided discovery. Guided discovery is the process by which the therapist serves as a guide for the client, in order to help them recognize their problematic cognitions and behaviors and also help them design new experiences (behavioral experiments) in which they might acquire new skills and perspectives (Beck & Weishaar, 1995). In addition, the therapeutic relationship provides an opportunity for the client to begin to make progress:
If the patient begins to feel better after the expression of feeling, this may then set up a favorable cycle. Since the depressed patient may have lost hope that he would ever be able to feel better again, this positive experience helps to restore his morale and also his motivation to cooperate in the therapy. Any evidence of feeling better is likely to increase the patient’s motivation for therapy and thus contribute to its efficacy. (pp. 43-44; Beck, Rush, Shaw, & Emery, 1979)
Although Beck focused much of his research on depression, cognitive therapy can be used to treat a wide variety of psychiatric and psychological disorders, including anxiety disorders, phobias, substance abuse disorders, anger and violence, and personality disorders (Beck, 1999; Beck & Emery, 1985; Beck & Freeman, 1990; Beck & Weishaar, 1995; Beck, Wright, Newman, & Liese, 1993; Pretzer & Beck, 2005). In Love is Never Enough (Beck, 1988), Beck extended cognitive therapy to working with couples. He had observed that many of his depressed client’s were in troubled relationships, and in other cases his client’s depression and/or anxiety had led to relationship problems. As Beck began working with couples, he found that couples were capable of the same cognitive distortions that individuals make, as each party within the relationship began focusing on the negative aspects of the relationship. As conflict grows, the partners blame each other, rather than seeing the conflict as a problem that can be resolved. Just as with individuals, cognitive therapy offers a means for breaking the cycle of conflict and miscommunication.
Discussion Question: Collaborative empiricism and guided discovery both suggest that the client must be an active member of the therapeutic team. In your opinion, is it possible for someone who needs therapy to help in their own recovery? Do you think there is a point at which the therapist must take over in order to ensure that therapy is successful?
Acceptance and Commitment Therapy (ACT) and Radical Acceptance
A recent development in cognitive therapy shares an ancient tradition with Eastern philosophies: mindfulness. Mindfulness training involves learning to accept one’s emotional realities, and one of the most significant realities is that much of human life involves suffering. Starting with these basic observations, Steven Hayes and his colleagues have developed Acceptance and Commitment Therapy (ACT; Hayes & Smith, 2005; Hayes, Strosahl, & Wilson, 1999; see also Eifert & Forsyth, 2005; Hayes, Follette, & Linehan, 2004). Hayes and his colleagues do not mean acceptance in the sense of resigning oneself to suffering, but rather in the sense of accepting life as it comes. Then, one must commit oneself to moving forward and living a values-based life, regardless of the presence of challenges:
The constant possibility of psychological pain is a challenging burden that we all need to face…This doesn’t mean that you must resign yourself to trudging through your life suffering. Pain and suffering are very different. We believe that there is a way to change your relationship to pain and to then live a good life, perhaps a great life, even though you are a human being whose memory and verbal skills keep the possibility of pain just an instant away. (pg. 12; Hayes & Smith, 2005)
Although Hayes and his colleagues make passing reference to mindfulness as a Buddhist teaching, they do not take a spiritual approach with ACT. They do, however, acknowledge that psychologists often make the mistake of ignoring spiritual practices that might prove helpful to their clients (Hayes, Strosahl, & Wilson, 1999). Many people in psychology today, including Ellis and Beck, recognize that cognitive psychology began with the Buddha some 2,500 years ago (Ellis, 2005; Pretzer & Beck, 2005; see also Olendzki, 2005). Dr. Tara Brach, a clinical psychologist and teacher of mindfulness meditation (also known as vipassana, which means “to see clearly”), makes no qualms about following a Buddhist approach to therapy. In Radical Acceptance: Embracing Your Life with the Heart of a Buddha (Brach, 2003), Brach talks about living in a trance of unworthiness. Plagued by beliefs of their own inadequacies, some individuals limit their ability to live a full life. Consequently, they cannot trust that they are lovable, and they live with an undercurrent of depression or helplessness. They then embark on a series of strategies designed to protect themselves: they attempt self-improvement projects, they hold back and play it safe, they withdraw from the present moment, they keep busy, they criticize themselves, and they focus on other’s faults. Radical Acceptance as a therapeutic approach involves both mindfulness meditation and Buddhist teachings on compassion as a basis for teaching people to accept themselves as they are:
Radical Acceptance reverses our habit of living at war with experiences that are unfamiliar, frightening or intense. It is the necessary antidote to years of neglecting ourselves, years of judging and treating ourselves harshly, years of rejecting this moment’s experience. Radical Acceptance is the willingness to experience ourselves and our life as it is. A moment of Radical Acceptance is a moment of genuine freedom. (pg. 4; Brach, 2003)
Mindfulness as a therapeutic technique has also been used by a variety of other therapists: in couples therapy (Christensen, Sevier, Simpson, & Gattis, 2004; Fruzzetti & Iverson, 2004), following traumatic experiences (Follette, Palm, & Rasmussen Hall, 2004), and for the treatment of eating disorders (Wilson, 2004) and substance abuse (Marlatt, et al., 2004). Janet Surrey, one of the founding members of the Stone Center Group, has favorably compared relational psychotherapy to mindfulness (Surrey, 2005), and Trudy Goodman, who studied child development with Jean Piaget, uses mindfulness in therapy with children (Goodman, 2005). Thus, whether in the more structured approach of ACT or Radical Acceptance, or in more informal ways in the hands of therapists familiar with mindfulness meditation, paying attention to the mind in a calm and careful way is becoming an important trend in psychotherapy. According to Steven Hayes (2004), this approach represents a third wave in behavioral-cognitive therapy, following traditional behavior therapy and then the cognitive therapies of Ellis and Beck. This third wave is also the basis for the popular and influential work of Jon Kabat-Zinn (1990, 1994, 2005; see also Germer et al., 2005) and connects behavioral and cognitive theories to the rapidly growing field of social neuroscience (the study of the interactive influences between the structure/function of the brain and social behavior; see, e.g., Begley, 2007; Cacioppo et al., 2006; Cozolino, 2002; Harmon-Jones & Winkielman, 2007; Siegel, 1999, 2007).
Theory in Real Life: Beck’s Cognitive
and the Treatment of Personality Disorders
Aaron Beck and a number of his colleagues, as well as others, have attempted to apply cognitive therapy to the treatment of personality disorders. It is widely accepted that personality disorders are highly resistant to treatment, but aside from the problems they present by themselves, there is another important reason to continue trying to address these serious psychological disorders. Personality disorders often co-occur with other psychological conditions (Axis I disorders), and they may be the primary reason why psychotherapy does not work well with certain patients (Pretzer & Beck, 2005). Since cognitive therapy in particular requires that the therapist gain an understanding of what the client is thinking, in order to then help the client recognize their own dysfunctional cognitions so that the client may work toward change, it is necessary for the therapist to have a complete understanding of the client’s psychological make-up. As a prelude to treating personality disorders with cognitive therapy, one needs to understand personality disorders in cognitive-behavioral terms.
As with depression, or any other psychological disorder, the cognitive-behavioral perspective suggests that individuals suffering from personality disorders have formed dysfunctional schemas that create an attributional bias, which then causes the person to interpret life’s experiences in dysfunctional ways, but in ways that nonetheless support and maintain the dysfunction of the personality disorder. If this theory is accurate, one should be able to identify typical patterns of dysfunctional schemas that match the characterization of different personality disorder diagnoses. Indeed, Beck and Freeman (1990) have offered those patterns in Cognitive Therapy of Personality Disorders. What distinguishes the negative schemas that characterize personality disorders from schemas that characterize other psychological disorders reflects the basic difference between Axis II and Axis I in the DSM system:
The typical schemas of the personality disorders resemble those that are activated in the symptom syndromes, but they are operative on a more continuous basis in information processing. In dependent personality disorder, the schema “I need help” will be activated whenever a problematic situation arises, whereas in depressed persons it will be prominent only during the depression. In personality disorders, the schemas are part of normal, everyday processing of information. (pg. 32; Beck & Freeman, 1990)
What might the typical schemas associated with other personality disorders be? Beck and his colleagues offer detailed examples for all ten of the personality disorders listed in the DSM, as well as for the passive-aggressive (negativistic) personality disorder (Beck & Freeman, 1990; Pretzer & Beck, 2005). To cite just a few examples, the antisocial individual thinks that “people are there to be taken,” the narcissistic individual thinks “I am special,” and the histrionic individual believes “I need to impress.” As a result of these basic beliefs and attitudes, these individuals adopt corresponding behavioral strategies. The dependent person seeks attachment, the antisocial person attacks, the narcissist engages in self-aggrandizement, and the histrionic person performs dramatically (Beck & Freeman, 1990).
How does a personality disorder arise, according to the cognitive-behavioral perspective? First, there are inherited predispositions that may represent primeval strategies. For example, Beck has suggested that the antisocial personality reflects a predatory strategy, whereas in contrast, the paranoid personality reflects a defensive strategy (see Pretzer & Beck, 2005). Second, the characteristics of personality disorders can result from social learning, especially when the social environment enhances genetic predispositions. A child born with a shy disposition, in a household that seems threatening and/or confusing, may naturally withdraw. That withdrawal, taken to its extreme, is a strategy compatible with the avoidant personality disorder. And finally, there is the possibility of traumatic experiences during development. Personality becomes well established during childhood. If one’s experiences during this important time are dysfunctional and traumatic, the individual is likely to develop a personality that has ingrained dysfunctional schemas, thus affecting the individual’s life from that point forward. In this model, personality disorders are not necessarily any different in form than other psychological conditions, but since they directly involve one’s relationship with others, they become significant, problematic features of one’s daily life:
…The cognitive view of “personality disorder” is that this is simply the term used to refer to individuals with pervasive, self-perpetuating cognitive-interpersonal cycles which are dysfunctional enough to come to the attention of mental health professionals. (pg. 61; Pretzer & Beck, 2005)
The basic approach to treating personality disorders with cognitive therapy is not different than usual, but does require some special attention to detail:
Personality disorders are among the most difficult and least understood problems faced by therapists regardless of the therapist’s orientation. The treatment of clients with these disorders can be just as complex and frustrating for cognitive therapists as it is for other therapists…For cognitive therapy to live up to its promise as an approach to understanding and treating personality disorders, it is necessary to tailor the approach to the characteristics of individuals with personality disorders rather than simply using “standard” cognitive therapy without modification. (pp. 44-45; Pretzer & Beck, 2005)
Based on this concern, Pretzer and Beck (2005) have offered a list of twelve key elements that require attention when using cognitive therapy to treat an individual with a personality disorder:
Interventions are most effective when based on an individualized
conceptualization of the client’s problems.
2. It is important for therapist and client to work collaboratively toward clearly identified, shared goals.
3. It is important to focus more than the usual amount of attention on the therapist-client relationship.
4. Consider beginning with interventions which do not require extensive self-disclosure.
5. Interventions that increase the client’s sense of self-efficacy often reduce the intensity of the client’s symptomatology and facilitate other interventions.
6. Do not rely primarily on verbal interventions.
7. Try to identify and address the client’s fears before implementing changes.
8. Help the client deal adaptively with aversive emotions.
9. Anticipate problems with compliance.
10. Do not presume that the client exists in a reasonable environment.
11. Attend to your own emotional reactions during the course of therapy.
12. Be realistic regarding the length of therapy, goals for therapy, and standards for therapist self-evaluation.
Despite these straight-forward steps toward effective cognitive therapy, it seems clear from looking at them that there are going to be challenges when dealing with clients who have a personality disorder. Indeed, the very process of collaborative empiricism can be quite difficult with these clients. Beck & Freeman (1990) have identified nineteen problems associated with establishing an effective collaboration with clients who have a personality disorder:
patient may lack the skill to be collaborative.
2. The therapist may lack the skill to develop collaboration.
3. Environmental stressors may preclude changing or reinforce dysfunctional behavior.
4. Patients’ ideas and beliefs regarding their potential failure in therapy may contribute to noncollaboration.
5. Patients’ ideas and beliefs regarding effects of the patients’ changing on others may preclude compliance.
6. Patients’ fears regarding changing and the “new” self may contribute to noncompliance.
7. The patient’s and therapist’s dysfunctional beliefs may be harmoniously blended.
8. Poor socialization to the model may be a factor in noncompliance.
9. A patient may experience secondary gain from maintaining the dysfunctional pattern.
10. Poor timing of interventions may be a factor in noncompliance.
11. Patients may lack motivation.
12. Patients’ rigidity may foil compliance.
13. The patient may have poor impulse control.
14. The goals of therapy may be unrealistic.
15. The goals of therapy may be unstated.
16. The goals of therapy may be vague and amorphous.
17. There may have been no agreement between therapist and patient relative to the treatment goals.
18. The patient or therapist may be frustrated because of a lack of progress in therapy.
19. Issues involving the patient’s perception of lowered status and self-esteem may be factors in noncompliance.
Although Beck and his colleagues offer more details and specific clinical examples in their writings (Beck & Freeman, 1990; Pretzer & Beck, 2005), the preceding lengthy list of problems a therapist is like to encounter clearly suggests that working with these clients is difficult at best. So, is cognitive therapy effective in the treatment of personality disorders? Numerous uncontrolled clinical reports suggest that it is, but the small number of controlled studies have offered equivocal results. More important, however, is the reality of “real-life” clinical practice:
In clinical practice, most therapists do not apply a standardized treatment protocol with a homogenous sample of individuals who share a common diagnosis. Instead, clinicians face a variety of clients and take an individualized approach to treatment. A recent study of the effectiveness of cognitive therapy under such “real world” conditions provides important support for the clinical use of cognitive therapy with clients who are diagnosed as having personality disorders… (pg. 102; Pretzer & Beck, 2005)
So what can we conclude from this discussion? There is consensus that personality disorders are prevalent in our society and they are resistant to treatment. Cognitive therapy, and the theory underlying it, has offered a promising avenue for further research. Given the significant impact of personality disorders on both individuals and society as a whole, any promising line of research deserves to be pursued vigorously
Review of Key Points
- Personal construct theory emphasizes the cognitions that precede behavior, even more than one’s ability to accurately predict behavior.
- Kelly used the term man-the-scientist to describe how each person creates and tests representations of the world, in an effort to predict and control their environment.
- Our representations, or constructs, are open to revision, and there are always alternatives. The process by which we test and modify our constructs is called constructive alternativism.
- Personal construct theory begins with a fundamental postulate, which is then elaborated with eleven corollaries.
- Personal constructs regularly undergo transition, from ineffective constructs to more effective constructs. Problems with these transitions may result in feelings of threat, fear, guilt, or anxiety.
- There are two typical cycles of transition: the C-P-C Cycle and the Creativity Cycle. The first involves circumspection, preemption, and control. The Creativity Cycle requires beginning with loose constructions and then rapidly testing and pursuing new and effective constructs.
- Creativity appears to be an important component of healthy psychological functioning.
- Both the therapist and the client bring their own conceptualizations about therapy into the therapeutic process. The ultimate goal is to help the client generate movement forward, such that the process can continue after therapy has ended.
- In order to facilitate cognitive-behavioral therapy within his theoretical framework, Kelly developed an assessment tool known as the Role Construct Repertory Test and a therapeutic procedure known as fixed-role therapy.
- In diverse settings, it is essential for therapists to be familiar with cross-cultural issues related to therapy in order to understand the nature of a client’s constructs and schemas.
- Ellis proposed an ABC theory of personality: activating events lead to beliefs about a situation, and those beliefs lead to the consequences of the event.
- Rational emotive behavior therapy was designed to dispute the client’s irrational beliefs, thus leading to effective new philosophies, emotions, and behaviors.
- The straightforward nature of rational emotive behavior therapy, and Ellis’ willingness to write for a popular audience, was a major factor in establishing the self-help genera.
- Rational Recovery, based on rational emotive behavior therapy, was developed as an alternative to Alcoholics Anonymous. In particular, it does not include the religious requirements of AA.
- Rational emotive behavior therapy was challenged as being atheistic. Ellis later wrote that he is not opposed to spirituality, but he is opposed to dysfunctional, dogmatic religious beliefs that hinder one’s personal growth.
- Ellis openly challenged the value placed on self-esteem, suggesting instead that what is important is acceptance of ourselves, including our flaws and mistakes.
- Beck developed his cognitive therapy while conducting research on depression.
- Beck’s cognitive model is based on automatic thoughts, schemas, and cognitive distortions. Depression in particular results from a cognitive triad: a negative view of past, present, and future.
- Cognitive therapy offers an active, directive, time-limited, and structured approach to psychotherapy.
- Cognitive therapy involves collaborative empiricism and guided discovery. Hopefully, the client is able to learn skills that will allow them to continue improving their life even after therapy has ended.
- Acceptance and Commitment Therapy incorporates mindfulness into a modern therapeutic process, emphasizing the acceptance of one’s suffering in life followed by moving forward and living a values-based life. Radical Acceptance incorporates traditional Buddhist mindfulness practice (vipassana) into the therapeutic process.