Cognitive-Behaviorism Comes of Age

Grounding symptomatic treatment in an existential approach

Cognitive-Behaviorism Comes of Age

This article first appeared in the January/February 2002 issue.

Cognitive-behavioral therapists are still often dismissed as simplistic, shallow and reductionistic by clinicians who know nothing about it except what they vaguely recall about rats running mazes from undergraduate psychology classes long ago. According to common caricature, we reduce all human distress to superficial, bite-size behavioral symptoms and maladaptive thinking habits, then apply standardized techniques to train people, rat-like, into acquiring new behaviors and new thoughts. Many concede that this primitive kind of intervention is all well and good with straightforward phobias and simple anxieties. But we are frequently accused of ignoring the “deeper” layers of human experience, and told that our blinkered method makes it virtually impossible for us even to form a resonant therapeutic alliance, much less help people deal with “serious” issues like trauma, grief and loss, troubled relationships or the meaning of life and suffering.

While there was some truth to this cramped and narrow vision of cognitive-behavioral therapy 30 years ago, it severely misrepresents the way we work today. Now, we begin with the assumption that people do not come to a therapist because they experience “errors in thinking,” but because they feel bad. To sidestep emotion would seriously undercut our ability to help people deal with the cognitive distortions that keep them stuck in self-perpetuating cycles of misery and incapacity. So, while we don’t dwell on emotions at great length in therapy, or speculate endlessly about their causes, we believe it is critical for people to face, experience and accept their feelings of loss, fear, anger and grief–particularly in the aftermath of trauma.

More important than just “getting in touch” with their feelings, however, traumatized clients often need to readjust their entire relationship to a world that suddenly seems starkly frightening, chaotic and out of control. Unlike cognitive-behavioral therapists of three decades ago, we direct much of our effort to helping clients make a deep existential shift–to a new understanding of the world. At the same time, we try to remain true to our roots in a method that is practical, systemic, concrete, brief and rigorous. Along with helping clients face squarely the inescapable reality of grief and pain, we address their specific symptoms and give them the tools to live fully even in the hard knowledge that life is always a gamble. The direction of therapy is more forward into the future than backward into the past.

A False Sense of Control

My work with Celeste illustrates this integration of existential and trauma-focused approaches with classic cognitive-behavioral methods. Celeste was a veteran international flight attendant referred to me by her airline’s Employee Assistance Program because she was having disabling panic attacks. With tears in her eyes, she related a story of trauma that has tragically become all too relevant given the devastating events of September 11.

For more than 30 years, she had flown regularly to Europe and had always loved her work. A few months earlier, however, Celeste had asked a fellow flight attendant to switch flights so that she could attend a family reunion. The other attendant–a bright, young rookie who had just gotten engaged–agreed. On the day of the reunion, the jet liner exploded in a ball of fire only minutes after takeoff, killing several hundred passengers and close to 30 crew members, including Celeste’s friend.

Celeste was devastated, as were many in her industry. She found herself haunted by the thought that she had caused the death of her coworker, who had been her daughter’s age. She repeatedly told herself and her family, “I was supposed to die on that flight. That was my intended fate. Death is not easily cheated, and I cheated it at the expense of someone else.”

This ferocious regime of self-recrimination fueled a runaway train of obsession, difficulty eating and sleeplessness. Incessantly nervous and prone to hyperventilating, she began to experience panic attacks so serious that she had to call in sick for the first time in her career. Trained to be calm and cool under all circumstances, she found herself unable even to board a plane without feeling faint and nauseated. Because she was a practical, take-charge sort, who had rarely if ever felt she was not entirely in control of her own life, Celeste had no interest in prolonged psychotherapy or in exploring the nether regions of her own emotions. She wanted me to get rid of her symptoms fast and return her to flying.

Before the 1980s, most cognitive-behavioral therapists would have assumed that Celeste’s anguish was produced mainly by faulty thinking; they would have concentrated purely on modifying her thoughts and getting her to expose herself to flying again. Clinicians would have taught her relaxation techniques, pointed out her irrational thinking patterns, subjected her to gradual desensitization aimed at purely behavioral change–boarding a plane without having a panic attack. That approach would have worked in the short run, but I have found during more than two decades of work that for clients like Celeste the relief would probably not last. After getting to know Celeste, I felt sure that the plane crash triggered her symptoms–irrational guilt and obsession that kept her in a state of perpetual dread–but didn’t cause them. I had the sense that she was insisting upon her “responsibility” for her friend’s death in order to avoid more painful feelings of grief, rage and helplessness–particularly the last.

Throughout her life, Celeste had been as unfamiliar with the deep upwelling of unpleasant emotion since she was used to being in control of herself and her surroundings. Raised by a family that prized self-reliance and regarded emotional expressiveness (particularly the negative kind) as self-indulgent and undignified, she grew up feeling that “letting it all hang out” was an embarrassing lapse. Instead of consciously experiencing natural sadness, anger and helplessness caused by the crash, Celeste fought these feelings, channeling her mental and emotional energy into another set of essentially fictitious emotions, including unrealistic guilt and obsession. Self-blame, irrational as it was, still allowed her to maintain a false sense of agency and control, as if somehow she could have foreseen the crash or stopped it from happening.

When I explored with her the possibility of changing her view of emotional expression, she told me it felt disloyal to her, as though she were making fun of her family and devaluing them. Not only did she assume she had no right to grieve, she didn’t even have the right to question that assumption.

Celeste’s learned responses to emotion were limiting her ability not only to  feel her natural grief and rage, but even to  think deeply about what the tragedy meant to her. What thoughts did it evoke about life and death? How could she honor her friend’s memory while accepting her death? How was anyone to make sense of such a senseless disaster? These are not just pointless ruminations; they both console us and help us find some kind of mental and emotional resolution in the midst of suffering. When we can reconcile ourselves to the realities of life and accept our weakness and inability to control much of anything at all, then we have a shot at healing, happiness and even wisdom.

Expressing Emotion

I wanted to offer her enough symptomatic relief to give her hope, but I told her that to address only her superficial symptoms and behaviors would be analogous to using a topical skin cream to treat a systemic disorder that has produced a skin rash. I could make her symptoms abate, but if we never disentangled the root causes, they might very well come back in another form. She agreed to explore with me the root causes of her symptoms in addition to finding ways to make them abate.

So, rather than simply accept her explanation of guilt as the cause of her suffering, and in opposition to what many think of as the cognitive-behavioral approach, I began by working with her, not to help her “button things up” but to express more emotion. Instead of assuming (in classic cognitive style) that troublesome emotions result only from faulty thinking, I believe emotions have independent, adaptive and healing functions of their own.

As trauma therapists have argued for much of the past two decades, it is not uncommon for individuals who are grieving to experience intrusive thoughts about the individual or individuals being grieved for and alternating between feelings of sadness, pain and anger. Beneath Celeste’s obsession and guilt, therefore, I assumed there were more primary emotions: grief at her coworkers’ deaths, fear of her own death and anger at not having more control over their fate and her own. In treatment, we focused on helping her attend more fully to her felt bodily sense of anger and anxiety. For example, Celeste would often begin to tremble, and we discovered together that this physical symptom was more a symptom of unwelcome anger at being unable to control events or her own emotional reactions to them than the fear of panic.

I encouraged Celeste to express her grief and anger through crying, talking about her dead coworkers, attending memorial services and so on. I advised this very restrained, disciplined and self-contained woman to deliberately let herself “lose it” with her coworkers–yell, cry, throw something, pound her desk, admit that she was at her wits end–when she was around her coworkers. “When people ask you how you are doing, tell them straight out that you are miserable, that you don’t know what to do with your anger,” I told her. I also pointed out that other people with whom she worked would welcome seeing that she was as humanly grief-stricken as they were.

At the same time, I was helping Celeste learn to express emotions more freely, I also remained mindful of our therapeutic alliance in a way that cognitive-behaviorists once ignored. It has often been de rigueur for us to take a very directive stance in therapy–reshaping cognitive constructs, educating, coaching, interrupting habitual patterns of thinking and acting. But, in Celeste’s case, it was important (though hard, sometimes) for me to refrain from rushing in to “help” her. Coming to terms with her own human vulnerability was something she had to do in her own time.

Letting Go

Helping her make a connection between her emotions and the traumatic event was an important milestone for Celeste, because it enabled her to viscerally experience her human vulnerability. This emotional work prepared the way for examining Celeste’s  schemas,  a major intellectual component of contemporary cognitive therapy. Schemas are templates–learned ways of filtering and structuring incoming experience. Celeste’s schemas, for instance, held that it was catastrophic not to be in control,  and that she or those she loved would suffer if she did not work at maintaining control. She also held to the belief that things like this shouldn’t happen; it is wrong for them to happen.

We explored the roots of these beliefs in Celeste’s upbringing, and–this is another cognitive-behavioral piece–practiced changing her behavior out in the world. For example, she restrained herself from peremptorily ordering her daughter in marine-sergeant tones to stop seeing a man whom Celeste thought was a philandering, smooth-talking con artist. Instead of trying to engineer her daughter’s behavior by sheer force of will, she quietly told the young woman about her concerns, admitting that it wasn’t her choice to make, and that it was up to her daughter to do what she thought was right. Celeste managed this feat of self-control by reciting to herself a kind of mantra: “Whatever is going to happen will happen . . . let it go, let it flow, accept life as it comes.” For Celeste, a woman who sometimes seemed to think she could and must put to rights every human error she saw, this accession to philosophical acceptance was a transformation indeed.

None of this happened overnight. Over the course of many months, Celeste gradually learned to ask and then to think about questions she had ruthlessly put away from her at first: “Why was I spared?” “Why do things like this happen?” “How do you go on living in the face of death?” Of course, there are no set “answers” to any of these questions, but the ability to ask them and contemplate one’s own individual answers provides the grounding for a mature acceptance of life on life’s terms. Paradoxically, once comfortable with the reality of life’s inevitable risk, clients find themselves able to relinquish many of the anxieties and fears that have long been their bulwark against uncertainty.

Celeste called upon old religious beliefs that, she said, reassured her that her dead coworkers were now happy and no longer suffering. It was with something of a small shock that thinking about her faith made her realize that the grief she now openly expressed was not so much for the ones who had died–they were beyond grief and misery–but for herself, not only for the loss of them, but for the loss of her own armor, her implicit belief in her own invulnerability.

Flying Once More

Notwithstanding our discussions about weighty issues of life, death and the existential meaning of trauma, I did not junk classic behavioral and cognitive techniques. While we were talking about the “big” questions, we were also doing practical work with standard techniques of exposure, cognitive restructuring and progressive muscle relaxation to reduce and then eliminate the panic attacks that had brought Celeste into my office. I taught her, for example, to interrupt her catastrophic interpretations of her dizziness and quickening heartbeat and understand them as relatively benign manifestations of her body’s alarm system.

We also progressively practiced in vivo exposure. First, after learning progressive muscle relaxation and deep breathing, she spent time in the airport–that “get back up there” technique used with wartime pilots to ensure that avoidance doesn’t progressively increase anxiety. Next, she took a short domestic flight as a passenger. Then, still using progressive muscle relaxation, deep breathing and calming thoughts, she worked a short flight, and then a longer West Coast assignment.

By this time, she had reduced her anxiety enough to get on a plane and, once there, to control her autonomic responses using thought statements developed in therapy–not blaming herself, but accepting situations for what they were. She frequently told herself, “I guess I just have to let myself off the hook.” Finally, after 13 sessions, she returned to overseas flying, though she continued seeing me for another 12 sessions to consolidate our gains and get more practice in living within a changed world view.

As in many cases, this one didn’t end dramatically. Celeste simply stopped coming when things were better. Her panic attacks had stopped. But more important to me, she had restructured her thinking to include the notion that life is messy and unpredictable, and the only thing that we can do about this is to accept it on its terms and not try to distort reality to try forcing it into a pattern we desire. Restructuring a life-long philosophical orientation is not the kind of project that we can expect to complete in several hundred sessions, much less 25. But cognitive-behaviorist therapy done within an existential framework can begin the process of real life transformation. This kind of work can mean much more to clients than interventions that simply train them to tolerate higher levels of stress.

Exploring existential issues of meaning while also giving people the cognitive-behavioral tools to deal with life on a day-to-day basis not only encourages more adult thinking, it protects against despair. Clients learn skills for dealing with life’s uncertainties and actually have a greater sense of realistic agency and power than they did when they believed they should control the world–a belief doomed to inevitable, crushing disappointment. In the long run, learning to accept one’s own vulnerability and ultimate helplessness actually makes one stronger and freer.

Case Commentary

By David Waters

This isn’t a case about the relative merits of cognitive-behavioral therapy (CBT); it’s a case that utilizes a number of major therapeutic approaches to deal with a powerful conflict. Frank Dattilio gives us a straw man of shallow ’60s behaviorism to work off of, but then sets out a very nice array of creative, sound ways to work on the problem–and cites it as a triumph of modern CBT. I’ll give him the triumph–overall the case is nicely handled, and had results for Celeste far beyond symptom reduction–but not the kudos for CBT.

The longer I work in this field, the more all good therapy starts to look alike. There are exceptions–EMDR, for example, is quite unusual and sui generis (and not always good therapy) –but, in general, good therapy goes back to what Claude Rains said in Casablanca : “Round up the usual suspects.” A strong relationship, a clear and honest dialogue, a safe place for experiencing strong emotion, time to reflect in depth and challenge old beliefs–these elements and a few others are the heart and soul of good therapy in any school. But there’s an additional item that’s crucial to success, and highly dependent on the acumen of the therapist, and that is focusing on a really important, useful and appropriate goal for therapy. If you’re going after the right variables, the method doesn’t matter much.

In this case, Dattilio does a nice job of seeing a larger, more powerful, pattern behind the symptom and framing a clear goal with Celeste. As so often happens, her apparent strength is also her weakness, and what she thought she wanted–to feel strong and invulnerable again–is exactly the opposite of what she needed. Dattilio sniffs this out nicely and helps Celeste ease up on her need for control enough to get interested in this fundamental “deep existential shift.”

But it’s hard to see the case as a triumph of CBT. There are prominent aspects of a number of approaches–family systems therapy, mindfulness meditation, narrative therapy (Dattilio calls narratives “schemas”) and psychodynamic attention to unconscious processes, to name a few. Almost any school could recast this case in its own vernacular effectively, in part because the goals and the heart of the work are powerful and universal. The use of specific CBT methods, like relaxation and desensitization, are appropriate and effective, and I think many of us would have used some version of them to help Celeste handle her anxiety about flying again. Even in the midst of a deep existential shift, people need help getting back on the horse. But one good desensitization does not a CBT case make.

This is pretty eclectic stuff, and speaks more to the variety of methods that go into good therapy, and the range allowed by a strong and helpful focus, than to the efficacy of modern CBT. “[A] mature acceptance of life on life’s terms” is a far healthier, more useful focus than I usually see CBT adopt, and says more to me about Dattilio’s maturity as a therapist than about CBT’s coming of age. He slips the chains of CBT over and over–he says so himself–and credits CBT with the escape. Growing up as a therapist means seeing the commonalities in our methods more than the differences, and the universality of powerful work as something more than a tribute to a particular school.

Author’s Response

Right you are, David Waters, this is a case that utilizes a number of therapeutic approaches. That’s exactly what constitutes the fabric of contemporary cognitive-behavioral therapy (CBT). It’s been stated repeatedly in the professional literature that CBT is the “eclectic psychotherapy” because it draws from so many different modalities.

I also agree that all good therapy does eventually sound alike. I don’t know of any psychotherapeutic modality that doesn’t blur lines. I am sure that even Claude Rains would agree with me on that.

So what’s the point? You say “Tomato,” I say “Tomahto”–both have seeds, are real messy to eat and both taste great when they’re ripe. CBT has evolved over the years to broadening its perspectives and embracing other modalities of treatment. Does this no longer make it CBT? I don’t think so.

And as for my “maturity” as a psychotherapist, I’ll be the first to tell you that I am no ripe tomato, but I do have a big tool box and like to use what works in therapy, regardless of what it’s called. So let’s go ahead and round up the usual suspects–Rains, Bogart, Waters . . . here’s looking at you, kid.

Frank Dattilio

Frank Dattilio, PhD, ABPP, is a clinical psychologist in private practice in Allentown, Pennsylvania. He’s on the faculty of psychiatry at Harvard Medical School and the University of Pennsylvania School of Medicine.

David Waters

David Waters, PhD, is a psychologist in private practice in Charlottesville, Virginia. He was a professor of family medicine and psychiatry at the University of Virginia Medical School for 37 years. He retired in 2008.