Book Review: Cognitive Therapy and the Emotional Disorders

Aaron T. Beck, the founder of modern cognitive therapy, in his book Cognitive Therapy and the Emotional Disorders, provides a clear and concise portrait of what cognitive therapy is, where and when it can be useful, and its relationship to other forms of psychotherapy. Devotion to common sense is the common vein that runs throughout the book. This lends credibility and coherenceto Beck's argument in support of cognitive therapy as the most appropriate form of psychotherapy in dealing with pure emotional disorders.

The essence of cognitive therapy is to lead the patient toward a more correct perception of the world and events so that their responses and interactions to/with the real world are appropriate. Beck notes that the first step of learning to distinguish between one's perception of the real world and the real world itself are essential to successful therapy. Once one understands how one is thinking about the world and one's self, one can then examine whether or not one's thinking actually corresponds to the real world. Identifying specific thought/imaging events which precede emotional responses to events/objects in the real world and evaluating these thoughts and images on how well they correspond to the real situation allows one to determine if the emotional response is appropriate. If one determines that the thought/imaging events that occurred as a result of the stimuli were inappropriate or just didn't adequately correspond to the realities of the stimuli then one can acknowledge the emotional response as inappropriate. Then, by changing the thought patterns and images which one has as a result of particular stimuli one is capable of changing the emotional response.

The situation in which cognitive therapy is most applicable is when the patient's ideational content in reference to a particular reality in the world is distorted. This causes their perception of the real world to be incongruous with the real world in which they act. If their actions are based of an incorrect view of the world, the result will be frustration and a vicious cycle of negative stimuli to fuel the patient's incorrect worldview. (p. 75) The inappropriate emotional responses are the "symptoms" which cause the patient to seek professional help. Beck does a good job of describing the inappropriate ideational content associated with each emotional disorder. He discusses phobias, paranoia, anxiety, depression, anger, obsessions and compulsions, and other emotional disorders.

What is most significant about Beck's book and the notion of cognitive therapy itself is that it demonstrates that many mental health problems are the result of inappropriate actions/ways of thinking that are under the control of the patient suffering from the problem. This means that not all mental health problems are the result of some unavoidable biological situation or traumatic event. One could theoretically divide mental health problems into two large domains: disorders associated withan inappropriate response to reality, or disorders associated with an abnormal and detrimental reality. This allows for the existence of appropriate periods of depression, anxiety, anger, and any other negative emotional state provided it is an appropriate response to a real stimuli and not just a response to a misperception of the stimuli.

            Acknowledging that many emotional problems have this particular cause as their root explains why there is such a stigma around mental illness. It is understandable that most people would consider someone with an unrealistic perception of the world and the resulting emotional problems to be "not really sick". But, regardless of whether or not the person is in fact "sick", that is, regardless of whether or not there is some sort of abnormal and detrimental reality afflicting the person they can and should be helped just like one would help a child who didn't yet understand that dogs were not all mean and vicious. Helping one another to better perceive reality is essential to living in community and there is no reason to ostracize those who are particularly "behind" in their perceptions of reality.

            Beck points out in the final chapters of the book that cognitive therapy, with its emphasis on documented records of patients ideational content allows it to be the most data driven of the psychotherapy techniques while providing much explanatory power. Behavior therapy allows for much documented evidence as well but it does not have the explanatory power of cognitive therapy, BT simply states the facts. Psychoanalysis on the other hand provides intricate explanations of emotional disorders but does not in fact do justice to the common sense data that is provided by asking the patient what they were thinking preceding the emotional response. Jumping to some intricate and far fetched theory of why a patient feels a particular way about a stimuli can help the patient to realize that the way they think/feel is not congruent with the external realities but it does so in a rather backwards manner. Another negative aspect of psychoanalysis is that it does not allow for data driven conclusions since the theories provided by the analyzer are only speculativeand cannot be verified.

            This book suggests an obvious problem we now have in dealing with mental health problems. It demonstrates that we can use cognitive therapy to help people who are not really broken; they are simply not using their tools properly. But what do we do with people who really do have the proverbial loose screw?  Yes, we can teach someone to use a sawzall or power drill (our mental faculties) that we all have in our minds but how do we help people who are missing a drill bit? Basically our current approach is to throw pills at them and see what happens. The domain of pharmacology is where we try to deal with these problems but unfortunately the amount of success we have is far from promising. Some patients, in addition to having a loose screw will develop distorted perceptions of reality as a result of their faulty screw. But, CT cannot work to correct the inappropriate perception until the screw is replaced and the machine made whole. Like the saying goes, if you try to reason with a crazy person all you are proving isthat you are crazy too.

            The basic assumption of CT is a common sense assumption that there is a single real world that we all perceive. We act based on our perceptions and our actions are successful in proportion to how accurately our perceptions match the real world. Any action in the world produces some sort of emotional response in the actor, either positive or negative. But, if the action is motivated by an incorrect perception of the world, the emotional response will always be negative because the action was inappropriate and cannot but fail 99.9% of thetime.

            So, cognitive therapy is appropriate and successful in dealing with a  particular category of mental health problems but it cannot solve all mental problems. It is an important step forward in understanding why most people feel and act the way they do but it cannot explain why the schizophrenic or the bi-polar person acts and feels the way they do. 

Beck, Aaron T. M.D. Cognitive Therapy and the Emotional Disorders. NY: International Universities Press, INC. 1976.