A Matter of Personality

From borderline to narcissism

The Limits of Cognitive Psychotherapy

Are people really as stupid as they seem?

Albert Ellis
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A type of psychotherapy known as cognitive-behavior therapy (CBT) is currently the predominant psychotherapy paradigm being taught in psychology graduate degree programs.  Its practitioners love to claim that their type of therapy is the most "evidenced based" of all psychotherapies and is therefore vastly superior to more humanistic and relationship-oriented types.

While it is true that they have more studies than anyone else, that is because they have very limited and simplistic treatment goals which are very easy to measure, unlike repetitive complex interpersonal patterns. They also rarely bother to study people who have a lot of different (co-morbid) psychological problems. Even so, their claims of the superiority of their evidence base are highly inflated. I went into exactly how in detail in my last book.

It is also true that CBT therapists control the funding for psychotherapy research and tend to deny the followers of other psychotherapy schools a chance to prove their mettle in randomized clinical trials, which are very expensive to do. Psychotherapy researchers who are not CBT therapists refer to the "cognitive behavioral mafia" at the National Institute of Mental Health.
Aaron Beck
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One of the major components of CBT is cognitive therapy, first pioneered by psychologist Albert Ellis and then refined (stolen?) by psychiatrist Aaron Beck. Cognitive therapy is based on the idea that human beings are irrational creatures in that they make a lot of logical errors whenever they assess the risks and benefits of various situations and courses of behavior. These irrational ideas then lead to out-of-control emotions such as unreasonable anger and depression

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When asked why people maintain irrational thoughts, Beck and Ellis say first that the reasons do not matter, and second that people are just born that way.   Sure, if you are looking for evidence of irrational human behavior, you do not have to look very far.  But that does not mean that people are basically as stupid as they seem to imply.

Ellis speaks of people "depressing themselves" with worst case scenarios (catastrophizing), or by drawing broad conclusions from single examples (e.g., "Since I failed this test, I will fail all the ones in the future" - overgeneralizing), or by setting up absurdly high standards for themselves with a lot of musts and shoulds that they can never live up to. He liked to refer to this process as "shoulding all over yourself" or "musterbating."

Cognitive psychotherapy employs a technique called collaborative empiricism. The patient and therapist get together to discuss the logical fallacies in some of the patient's thinking and to objectively examine the "evidence" for his or her beliefs. If the individual can become more of an objective, empirical, scientific type, he or she will not experience chronically negative emotional states - or so the reasoning goes.


A current and popular version of cognitive therapy is called Acceptance and Commitment Therapy (ACT). At slight risk of oversimplifying this therapy, it consists almost entirely of trying to teach people that they do not have to believe everything that they think.

It is interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in severe personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do. I believe that one reason for this is the existence of certain types of beliefs that human beings tend to hang on to as if their very lives depended on it, in spite of even the most obvious evidence to the contrary.

This type of belief was first identified by psychoanalytic pioneer Karen Horney. She referred to them as positive value blockages, for reasons I will describe shortly. They are held by individuals. Later on, family systems therapists noted a similar phenomenon in groups at the level of the family. They called these collectively held irrational notions family myths. Of course, dogmatic and preposterous myths are also

Karen Horney
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seen at the level of the subculture, where one might refer to them as theology.

A therapist who tries to challenge these beliefs almost invariably gets, in response, a version of "My mind is made up; don't confuse me with the facts." Trying to challenge the rationality of positive value blocks or family myths using cognitive therapy is like trying to convince a Birther that President Obama was born in Hawaii. 

The mental gymnastics people will employ to deny the obvious in these cases is nothing short of phenomenal. The definition of the word contradiction could be "something that such a person is seemingly unable to see."

One example was a patient who was absolutely certain that she could do absolutely nothing well and had no redeeming qualities whatsoever.  I tried to counter this with a therapy technique called reframing. Every time she came up with a new weakness that was supposed to characterize her, I would point out how the trait was actually strength in many contexts.  I would redefine her stubbornness, for instance, as persistence. 

The problem with my tactic was that she was much better at making lemons out of lemonade than I was at making lemonade out of lemons.  Each and every time I tried to reframe some attribute of hers as a positive one, she was able to redefine it as negative.  Finally, I said in exasperation, "You're really good at that.  I'm impressed.  No matter what I point out about you, you can figure out a way to turn it into something bad."  Her reply: "Oh, sure, the one thing I'm good at..."

Horney's idea of positive value blocks, which she conceptualized as defense mechanisms, is tied to the idea of a false self, which also called a persona. Children growing up in dysfunctional families who are subjected to rejection, brutality, withering criticism, ridicule, and/or hostile control will feel safer when they act in certain ways which are rewarded by the family environment, but which may run counter to the way they really feel deep down inside of them. The different sorts of behavior that fill this bill lead them to develop certain character types.

According to Horney, when such children - and later when they become adults - act in these ways, they often pretend to be proud of their behavior, but deep down they feel alienated from themselves and full of self-hatred. This neurotic or conflictual pride is a glorification of a phony self. This false pride is usually supported with a number of ideas which justify the character type. These ideas often take the form of proverbs or slogans such as, "Nice guys finish last." Such ideas act as blocks to the expression of a person's true self (which might wish to be nice), and this is what is meant by the term positive value blockages.

An individual's family often not only shares these beliefs, but lives by them. Some such beliefs can be applied only to certain individuals within the family (for example, what one family member is "really" like and who within the family he or she is closest to), while others apply to everyone. The ideas in this context are referred to as family myths. They justify and support a set of rules which dictate how each family member should behave, and what family roles each must fully and compulsively play, in order for the family to function in a predictable way (family homeostasis).

The myths function as a belief system which the family uses, often defensively, to explain its experience to itself. They are sometimes not verbalized explicitly so as to avoid any challenges to them. They can be taught implicitly through various forms of acting out and family rituals. However, they may also take the form of oft-verbalized adages just like positive value blockages do in individuals.

I had one patient who justified never trying to change a bad situation with three different proverbs: "The grass is always greener on the other side," "The devil you know is better than the devil you don't know," and "You've made your bed so now you have to lie in it." All three slogans had been repeated to her ad nauseam by her parents when she was growing up.

Therapists who challenge these ideas without understanding how central they are to a person's psychology do so at their own risk. Patients will fight them tooth and nail, and they will get absolutely nowhere. Cognitive therapists, put that in your pipe and smoke it. Or is that just another slogan for a family myth?

David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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