Response The Role of Emotion in Cognitive Therapy, Cognitive Therapists, and Supervision Christine E. Reilly, University of Delaware It is a myth that cognitive therapy does not address emotions. In fact, emotion is a primary variable in the cognitive model. The cognitive therapist facilitates identification of troubling emotions, helps the patient explore the origins of the emotion (automatic thoughts), and collaboratively generates alternative perspectives. Cognitive therapy supervisors help trainees learn to identify their own automatic thoughts and emotions and teach them how to use this information productively in therapy. This manuscript addresses these issues and includes some supervisory strategiesfor addressing therapists'emotions when these emotions interfere with the delivery of cognitive therapy.
EFOREwe can address the role of therapists' emotions in psychotherapy, we need to debunk the myth about the role of emotion in cognitive therapy. My experience in educating and training mental health professionals in cognitive therapy has led me to the conclusion that early identification of the "skeptics in the crowd" is imperative. Often the skeptics voice the concerns and questions of many individuals in the group. I have yet to present to a group of professionals where I do not hear someone raise the concern that cognitive therapy does not sufficiently address the patient's emotions.
The Role of Emotion in Cognitive Therapy The basic cognitive model has three components: Situation --+ Automatic Thoughts -+ Response (emotional, behavioral, and physiological), lndeed, patients do not often come to treatment saying, "My thinking is distorted." Rather, they present emotional distress such as sadness, anxiety, or irritability. Connecting with a patient and building rapport revolves around communicating an understanding of his or her emotional distress. This places emotion at the forefront of treatment from a cognitive perspective. Truly understanding the patient's emotional state, including its origins, is integral to the cognitive conceptualization of the patient. When working with the cognitive model, the patient's emotion signals the therapist to slow down and begin to identify and understand what is happening internally to the patient (what thoughts are occurring and what beliefs are activated). The first hint of tears should not lead the thera-
Cognitive and Behavioral Practice 7, 343-345, 2000 1077-7229/00/343-34551.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
pist to ask 101 questions about what is going through the patient's mind: This, of course, would risk shutting off the patient's emotional response. There is a fine balance between identifying the internal cognitive processes and respecting the pure affective response. A skilled cognitive therapist walks the balance beam between attending to the emotions and addressing the cognitive processing.
The Role of the Therapist's Emotions in Cognitive Therapy Given that the therapeutic relationship is one of the primary tools in psychotherapy (much like the scalpel is one of the primary tools in surgery), the influence of the therapist in the relationship is crucial. The therapist needs to cultivate an atmosphere of concern and caring to develop and nurture the therapeutic relationship. At the same time, there needs to be recognition that the therapist is human and has fluctuations in mood, energy, and concentration, among other variables, which may impinge on the therapeutic relationship. This is particularly notable when treating patients with a borderline personality disorder. These individuals, exquisitely sensitive to subtle interpersonal shifts, tend to protectively screen for perceived signs of impending rejection. They are apt to misinterpret a change in a therapist's typical behavior and attribute it to themselves. For example, having just recovered from the flu, I was slightly fatigued in a session with a long-term Axis II patient with borderline personality disorder. I will refer to her as "Mary." Halfway through the session, Mary seemed to disengage from the process. When I pointed this out to her and asked what was happening, she commented that I did not seem interested in her problem. I asked her what that thought meant to her and she reported that it probably meant I was giving up on her. We looked for the data that led her to that conclusion. She was able to see that she had personalized the sit-
uation and had j u m p e d to the worst possible conclusion regarding the session. I apologized for this and reassured her that while I was somewhat fatigued, I was extremely interested and concerned about her. We then examined how she may misconstrue other people's behaviors and draw erroneous conclusions. My willingness to validate her observations of me and explore alternative rationales for the shift in my behavior and energy level was therapeutically productive. One hallmark of cognitive therapy is the collaborative process between the patient and the therapist. Rather than operating on a hierarchical mode of being the "expert," the therapist needs to be a confident team player, cheerleader, and coach. Acknowledging the collaboraT h e t h e r a p i s t is tive piece of cognitive therapy includes recognizing the therhuman and has apist's emotional responses in f l u c t u a t i o n s in treatment and using them m o o d , energy, productively. For example, a therapist finds herself frusand concentration, trated after 25 minutes in the among other session and begins thinking, variables, which We are not making any progress here. In the spirit of collaboramay impinge on tion, the therapist could stop the therapeutic the session and say, "Gee, I relationship. may be missing the point here, and I am not sure where we are headed with this. What do you think we should do?" This kind of statem e n t allows the patient a chance to objectively examine what is happening in the session. It also empowers the patient to take a leadership role in the course of his or her treatment. What sets this therapeutic interaction into play is, of course, the therapist's recognition of his own emotion and identification of the preceding automatic thoughts. A cognitive therapist who really "buys into" the cognitive model uses it in everyday life. Assuming that therapists are attuned to their own affective responses, they will be identifying their own automatic thoughts when internal distress occurs. This is counter to the notion in the Najavits (2000) article, "Researching Therapist Emotions and Countertransference," which suggests that intense emotions, such as those found in countertransference, are largely outside of conscious awareness. Cognitive therapy teaches people how to identify emotion. For some people, particularly those with avoidant personality styles a n d / o r disorders, identifying affect is a new skill. This is true for therapists as well as patients. Learning how to identify and experience emotions is critical for any therapist, and is a skill a cognitive therapy supervisor will teach over the course of supervision.
The Role of Supervision in Cognitive Therapy Cognitive therapy is not an overly complicated model to learn. In fact, it is based on common sense. Many skilled professionals can take seminars, workshops, or courses in cognitive therapy and be able to teach the basic cognitive model reasonably well. However, this is quite different from doing cognitive therapy. Becoming a proficient cognitive therapist involves intensive clinical supervision. It is the supervisor's role to collaborate with the trainee and develop an approach to improving the therapist's skill in using the cognitive model. One of the first steps in this process is to encourage trainees to "practice what they preach." This often includes having trainees fill out their own dysfunctional thought records early in the course of supervision. Supervisors will pay attention to various red flags indicating the student may be struggling with a patient. For example, it is common for cognitive therapy supervisors to listen to students' audiotapes of therapy sessions on a weekly basis. A red flag would appear when the supervisor notes a change in the therapist's style, for example, a therapist arguing with a patient, cutting a patient off midsentence, speaking in a controlled tone, dominating the session, or, conversely, remaining particularly passive in the session. These are all clues that the therapist is having some negative automatic thoughts and feelings about the patient, or that something unusual is troubling the therapist. It is the supervisor's job to gently probe this with the therapist. If the therapist is unaware of what automatic thoughts or feelings he or she is experiencing, there are some exercises the supervisor can assign to the therapist. For example, the therapist could listen to the audiotape and count the number of times he or she interrupts the patient. Or the therapist could listen to the tape and record the automatic thoughts experienced while listening to the tape. The supervisor could do a role-play and take up the role of the patient, re-creating what happened in the session. When the therapist begins to display some of the above-noted behaviors, the supervisor could stop the role-play and ask the therapist what is going through his or her mind. If the therapist still struggles to identify personal emotions, the supervisor can make it more objective by asking the therapist how he or she thinks other colleagues would respond. In some cases, the supervisor might recommend that the trainee go into therapy, providing the trainee with several names and phone numbers of reputable cognitive therapists, with a statement about confidentiality. As Follette and Batten (2000) point out, students often feel vulnerable and fear a negative evaluation from their supervisor. This may inhibit them from sharing negative feelings and automatic thoughts about their patients with the clinical supervisor. Nezu, Saad, and Nezu
Emotions in Cognitive Therapy (1999) rightfully highlight the need for the supervisor to normalize emotional reactions. As therapists, we are trained to be accepting and nonjudgmental of patients. In fact, some branches of psychology (i.e., humanistic) espouse these qualities to be the mechanism of change for patients. Cognitive therapists see these qualities as essential but not sufficient for facilitating change. Certainly, cognitive therapy supervisors need to maintain an accepting, nonjudgmental approach to their supervisees. However, this needs to be coupled with an active empirical approach to address problems that arise in the delivery of treatment. It is important to r e m e m b e r that supervisors should also receive peer support. It is advisable that those who supervise others maintain their own network of peers to discuss supervisory struggles and supervisory successes. It is ideal to have weekly, or at least monthly, meetings where supervisors can discuss the progress of their therapists and problem-solve any difficulties in supervision. It is in this format that the supervisor can share dysfunctional thoughts and distress and brainstorm solutions. In summary, emotions are essential in cognitive therapy. The influence of the therapist on the therapeutic re-
lationship is significant and impacts the delivery of the treatment. Therapists are not computers. Therapists experience emotions, automatic thoughts, and physiological changes during patient sessions. Left unacknowledged, these experiences can obstruct good treatment. It is the job of the cognitive therapy supervisor to increase the trainee's awareness of these p h e n o m e n a and use them productively in treatment.
References Follette, V. M., & Batten, S. V. (2000). The role of emotion in psychotherapy supervision: A contextual behavioral analysis. Cognitive and Behavioral Practice, 7, 306-312. Najavits, L. M. (2000). Researching therapist emotions and countertransference. Cognitive and Behavioral Practice, 7, 322-328. Nezu, A. M., Saad, R., & Nezu, C. M. (2000). Clinical decision making in behavioral supervision: "... And how does that make you feel?" Cognitive and Behavioral Practice, 7, 338-342. Address correspondence to Christine E. Reilly, Ph.D., R.N., RO. Box 613, Devon, PA 19333.
Received: May 4, 1999 Accepted: March 1, 2000