Which model emphasized the idea that there had to be a physical cause of a mental disorder?

Beck's cognitive theory

Beck's cognitive theory considers the subjective symptoms such as a negative view of self, world, and future defining features of depression. The model assumes that psychopathological states represent extreme or excessive forms of normal cognitive, emotional, and behavioral functioning. Additionally, the cognitive theory posits that anxiety and depression can be distinguished by their cognitive content, with thoughts of personal loss and failure specific to depression and cognitive content involving physical or psychological threat and danger specific to anxiety. Although initially conceptualized as a model relevant to anxiety and depression, the cognitive model is now applied to a wide range of disorders such as eating disorders.

A central tenet of the cognitive theory is that our thinking influences our emotional and behavioral experiences and vice versa. As is described later, when applied in therapy, there is an emphasis on working toward changing one's thoughts as a means to altering feelings and behaviors. The basic model depicting the interrelationships among thoughts, feelings, and behaviors is displayed in Figure 1.

Cognitive theory has focused on thought processes that become habitual and automatic. These automatic thoughts are theorized to differ depending on the specific psychological problems a person is experiencing. How these thoughts become automatic is a matter of scientific study. Beck originally posited that individuals derive meaning from their experiences and, with time, rely on what he called cognitive schemas (i.e., hypothetical organizing structures of experience represented in thoughts) to provide meaning to experience. For example, someone with a history of limited close relationships may, over time, develop a schema like ‘I am unlovable.’ Schemas can constitute particular vulnerabilities to interpret certain types of experiences inaccurately. For instance, if a person believes they are unlovable, then they may interpret a colleague not inviting them to a party as further evidence of their unlovability rather than considering that the party was only for that person's family members or that they were actually invited but did not see the invitation.

Beck also developed the notion of the cognitive triad to describe how depressed adults tend to think about the world. The triad refers to thoughts about self, world, and future. In all the three instances, depressed individuals tend to have negative views. Thus, a depressed individual would tend to think they are a worthless person living in a futile and unforgiving world with a hopeless future. Beck's work also led to the identification of particular patterns of habitual and maladaptive thinking that he called errors of thought. These included the following:

arbitrary inference: Where an individual quickly and on the basis of limited evidence, draws a conclusion. Example: That person did not smile at me. He hates me.

selective abstraction: Where an individual focuses only on some of the available evidence to draw a conclusion. Example: My boss mentioned that my report needed some edits. He hated it.

overgeneralization: Where an individual takes one negative event and assumes that it has meaning that pervades his/her whole like. Example: I missed that shot. I am never going to succeed in anything.

Later in the article, a description of how Beck's theory has been applied to therapy is provided.

C: Cognitive Coping and Processing

During this component of treatment, the goal is to help the adolescent see the connection between thoughts, feelings, and behaviors. Worksheet 5a provides some structure for this discussion using the cognitive triad to illustrate and for soliciting helpful vs unhelpful thoughts and beliefs. This discussion can be tailored to the adolescent and, in the context of juvenile offenders, this offers a place for the therapist to discuss the offense committed and how they may relate to the adolescent’s beliefs and thoughts. Some of the exercises presented above under Affective expression and regulation can also be used here.

6.02.3.2 Cognitive Behavioral Therapy (CBT)

Cognitive therapy arose initially as a prominent treatment for depression. Aaron T. Beck developed CBT as treatment in the 1970s. Beck coined the term “automatic thoughts,” to describe thoughts individuals are often unaware of, that strongly influence feelings and behaviors. Beck's cognitive triad theorizes that depressed people have negative and hopeless thoughts or core beliefs about themselves, their experiences in the world, and their future (Beck et al., 1979). Schemas develop through a complex biasing process involving the interaction of genetic factors, selective allocation of attentional resources, and adverse environmental life events. Beck worked with individuals with psychological distress to help step outside of their automatic thoughts and test these beliefs using cognitive restructuring techniques.

The combination of cognitive and behavioral interventions led rise to identifying and treating triggering situation or emotions that lead to thoughts, which influence how one feels or behaves in a cyclical fashion. Over time, specific cognitive models have been developed for particular disorders, in order to treat each disorder distinctly and systematically. While current research continues to highlight the efficacy of CBT and cognitive behavioral conceptualizations, not all diagnoses respond similarly. Hofmann and Smits (2008)'s meta-analysis of randomized controlled trials utilizing CBT for anxiety disorders found that CBT showed the largest effect sizes for obsessive-compulsive disorder (OCD) and acute stress disorder, with smaller effect sizes for panic disorder. Another meta-analysis examined the efficacy of CBT for nearly every diagnostic category and found strong effect sizes for CBT in reducing psychological distress (Hollon et al., 2006). Specifically, anxiety disorders, bulimia, somatoform disorders, anger control problems and general distress were found to benefit most from CBT, whereas panic disorder and major depressive disorder showed fewer clear effects. Hollon et al. (2006) thus emphasized the importance of studying long-term outcomes.

Cognitive vulnerabilities

Cognitive distortions, or faulty patterns of thinking, may result from psychiatric disorders commonly diagnosed among suicidal youth, stressful events, or other early learning experiences. The presence of cognitive errors (e.g., overgeneralization, catastrophizing, selective abstraction, etc.), the cognitive triad (e.g., negative views of oneself, the world, and the future), and hopelessness (e.g., belief that life will not improve in the future) are commonly found among youth with depressive disorders and have been associated with suicidal behavior. However, study results have been somewhat mixed, particularly with regard to hopelessness, when severity of depression is controlled.

Adolescents' perception of their problem-solving ability has also been shown to influence their decision to engage in suicidal behavior. However, study results have been mixed and the nature of this association is somewhat unclear due to significant methodological differences across studies. Most adolescents who attempt suicide report that they believed that this behavior would permanently solve their problems (via death), provide a respite from their problems, and/or relieve their problems by letting others know that they need help. Generally, suicidal behavior appears to be more likely among adolescents who cannot view or generate alternative solutions to their problems, fail to select effective solutions, and/or lack confidence in their ability to solve problems. Conversely, belief in one's coping ability may protect against future suicide attempts.

Cognitive risks

Cognitive theories of depression emphasize the contribution of maladaptive mental representations and patterns of thinking to the onset and maintenance of depressive disorders. These theories posit that such cognitive attributes will have a particularly pronounced effect on depressive symptoms in response to negative life experiences. Three primary cognitive styles have been identified as risk factors for depressive disorders. The first depressogenic cognitive style (‘negative cognitive triad’) was proposed by Aaron Beck during the 1960s; according to Beck's theory, and more recent elaborations, dysfunctional attitudes predispose individuals to process information in a negatively biased manner. These maladaptive interpretations specifically pertain to inferences about the self (i.e., that one is flawed or inadequate), the world (i.e., that stressors will encompass all life domains), and the future (i.e., that negative experiences will persist in the future). A second depressogenic cognitive style (‘negative attributional or inferential style’) also highlights the role of negative inferences in response to stressful events; specifically, it is believed that individuals who attribute negative events to stable and global causes, who interpret negative events as having widespread detrimental consequences, and who perceive feelings of deficiency and hopelessness about themselves, as a result, are at heightened vulnerability to depression. A third depressogenic cognitive style (‘low perceived control’) involves the tendency to perceive oneself as incompetent and lacking control over life experiences, thereby priming the anticipation of perpetual life stress and emotional distress. Empirical research generally yields support for the notion that cognitive vulnerability, particularly in combination with stressful life events, predisposes adolescents to experience depressive symptoms.

6.03.2.1 A.T. Beck (Early Model)

Beck's early work (1963, 1967), related to thinking style in depression and later expanded to other emotional disorders (1976). He described the typical negative content of thought in depression as a pervasive negative view of the self, of the environment, and of the future (the negative cognitive triad), expressed in automatic, habitual thoughts in reaction to trigger stimuli. The negative automatic thoughts are maintained by various processing errors with a negative bias (arbitrary inferences, selective abstractions, personalizations, overgeneralizations, minimizations, and magnifications). These processing errors do not differ necessarily from the type of processing errors made by non-depressed individuals (labeled heuristics by Kahnneman, Slovic, & Tversky, 1982), the difference being in the direction of the bias, which is usually positive in the nondepressed, expressed as a self-serving bias (Taylor & Brown, 1988). The consequence of processing information with a negative bias is a congruent negative emotion. Thus, the information processing model of emotional disorders was set in a straightforward vertical or unidirectional model, which has since been reviewed. To explain why some individuals process information with such unhelpful biases, Beck evoked the concept of basic structures or schemata derived from cognitive science (Bartlett, 1932; Neisser, 1976; Piaget, 1950) These represent the sum of previous experiences, serving as templates that direct attention, influence encoding and interpretation of stimuli, and facilitate recall. In depression, the schemata reflect themes of loss and of self deficiency, for example, “unless I do everything perfectly, I am worthless” or “unless I do everything to please others, they will reject me.” It is noteworthy that at this stage of the theory, no differentiation was made between conditional schemata or basic assumptions, rules, and attitudes on the one hand, and unconditional schemata or core beliefs on the other, for example, “I am inadequate” or “I am unlovable.” An example linking the three elements described above would be:

Once the negative feeling is triggered, it is likely to feed forward and lead to other stimuli being interpreted negatively in accordance with the schema which has been activated and which becomes progressively more widely applied to inappropriate stimuli. Similarly, maladaptive behaviors, such as ruminations and inactivity, become preponderant and increase the incidence of negative automatic thoughts and the corresponding dysthymic moods. The typical schemata, beliefs, rules, and attitudes reflect themes of love, approval, entitlement, omnipotence, perfectionism, autonomy, and achievement, as measured by the Dysfunctional Attitude Scale (DAS) which was developed specially to assess this aspect of Beck's theory (Weissman & Beck, 1978)

The cognitive model of the anxiety disorders (Beck, 1976; Beck & Emery, 1985) followed the same principles, emphasizing specific patterns of thinking which differentiate these disorders from depression. Beck, Laude, and Bohnert (1974), in two studies designed to elicit thoughts and visual imagery associated with anxiety, found that anxious patients experience threatening thoughts or images which often precede attacks of anxiety. These thoughts relate to anticipated or visualized danger and extreme vulnerability. It was apparent that imagery was important in anxiety, an aspect that had not been stressed in depression, but which is emphasized in cognitive therapy (Edwards, 1989) The content of thought in anxiety was found to relate to an anxiogenic triad; seeing the world as threatening, the self as vulnerable, and the future as uncontrollable. This approach was similar to that of Lazarus (1966) who distinguished between two cognitive processes in anxiety, namely primary and secondary appraisal. Primary appraisal relates to an individual's evaluation of a situation as dangerous and threatening, whereas secondary appraisal relates to the evaluation of the self as not having the internal and/or external resources to deal with that situation.

The processing errors in anxiety do not differ essentially from those described in depression, but the schemata are likely to be different, referring to themes of personal vulnerability, of unpredictability, and of threat, for example, “If I feel anxious, this means I have no control of myself” or “I must always be on my guard, if not something awful will happen.”

As in depression, the dysfunctional schemata are self- or world-referent; they tend to be rigid and undifferentiated. These characteristics have been taken as implying that they have been learnt in early childhood and continue to survive through the process of assimilation, rather than accommodation (Piaget, 1977).

Psychological Theories of Depression

Understand That Negative Thinking Is Biased and Ineffective

In line with the more holistic and nature-focused approach to culturally adapting therapy for Asian heritage populations, the manual notes that sometimes our minds become polluted with negative thoughts and worry. Although negative thinking is natural, too much negative thinking can be damaging and counterproductive. Our thought processes can be compared to a river or stream of consciousness. This is what I like to call “flow,” which is a necessary part of our cognitive and mental health. As long as our thought processes flow naturally from one stage to the next, it is salutary to our mental health. However, every now and then, our thoughts may begin to stagnate and become stuck, affecting our ability to transition and flow from negativity and pessimism to optimism and action. Although life situations can drag us downward, sometimes we create or let our own thoughts fall into mental whirlpools and spiral into negativity. Sometimes life situations create or reinforce mental dams that block our river of thoughts, and we become trapped or stuck in pessimism. We lose our ability to “flow.” The goal of mental strengthening and cognitive reframing is to figure out a way to escape the whirlpool of negative thoughts, or to find a way to lift the floodgates of the mental dam and allow our thoughts to flow to the next place. “Flow” helps us emotionally reset and rejuvenate, and helps us become more centered, balanced, positive, and optimistic.

In this section, negative thoughts are separated into thoughts regarding yourself (“I am useless!”), your life circumstances (“I hate my job!”), the future (“Things will never get better”), and other people (“That person is such a jerk!”). This is a cultural adaptation of Beck’s cognitive triad, which was originally conceptualized as negative thoughts about the self, the present, and the future (Beck, Rush, Shaw, & Emery, 1979). Negative thoughts about “the present” was relabeled as “your life circumstances” to be culturally congruent with the goal-oriented and problem-solving nature of Asian heritage populations. Specifically, this cultural adaptation bridges psychoeducation about cognitions with the client’s life situation and goals for treatment. In addition, the original triad was culturally modified and expanded to include “other people,” which helped address the collectivistic and interdependent value orientation of Asian heritage populations. The manual emphasizes that too much negative thinking in these four domains can be unproductive and drain our emotional strength and energy. In addition, it can also be a waste of time and we sometimes spend more time worrying about a problem than actually doing something about it. Another way to culturally adapt Beck’s cognitive triad is to make adjustments for a person’s cultural orientation (ie, collectivism and interdependent self-construals vs. individualism and independent self-construals). Specifically, negative thoughts about oneself can be reconceptualized to include negative thoughts about others, or negative thoughts that others may have towards you.

The manual highlights that the goal is not to try to stop thinking negatively (which can be natural and healthy if circumscribed), but to spend more time thinking in healthy, productive, and effective ways. In fact, trying to expel negative thinking sometimes reinforces those thoughts and increases emotional distress. It is hard to force something out of one’s mind. For example, if somebody tells you to stop thinking about a watermelon, the picture of a watermelon keeps popping into your mind, and the more that we talk about the watermelon, the more you continue thinking about how green and red it is and how delicious it is during the summertime. Instead of trying to get rid of these thoughts, try to “flow” to your next thought (eg, grapes or strawberries, or the turkey sandwich you will be eating for lunch) to help shift our mental focus. Suppressing one’s thoughts and feelings to avoid mental suffering and pain is also not a good strategy. This can be likened to pushing a rubber duck down under the water in a bathtub. You can only hold it down for so long before it pops back up. Helping clients understand these concrete metaphors is an important cultural adaptation that bridges therapeutic concepts with everyday understanding.

The manual emphasizes more effective approaches to mental reframing, more balanced thinking, and strategies for increasing the amount of positive thoughts that we have. This ultimately helps decrease negative thinking and helps us escape from mental traps. When working with Asian heritage populations, therapists need to be very careful not to tell clients that there is something wrong with the way they are thinking, and that they are thinking in irrational, incorrect, or in problematic ways. These traditional cognitive therapy descriptors may lead to a greater defensive reaction among Asian heritage populations, who, at least initially during treatment, are more resistant to changing their thought processes than actively problem-solving.

Moreover, an emphasis can be placed on what we discussed earlier in the manual (eg, the differences between reacting and responding). Although some of us are naturally preconditioned to think more negatively than others, or influenced to think pessimistically because of various emotionally damaging life experiences, we are not predestined to emotionally suffer. Cognitive reframing and changing our internal dialog can be a very powerful and effective way of improving our mental health. We can change the natural reactions that we have by focusing on having healthy and effective responses. With repeated practice, eventually our responses can even replace our initial reactions and help us cope with life stressors. Therefore, there are many health benefits to mental strengthening and practice. The hope is that thinking positively and effectively will become as natural as riding a bicycle. Once we reinforce healthy mental reframing, we can quickly allow ourselves to flow from reactivity to responding, and focus more on handling the situation effectively. Just like negative thinking can be learned, our secondary responses are also malleable, and we can learn and refine cognitive skills. For many of us, intergenerational transmission of thinking patterns, communication styles, and coping strategies have created problems in our lives. Many of these intergenerationally transmitted problems (eg, ways of thinking or communicating) may have had some adaptive purpose in the family system, but may not be adaptive or functionally effective in other situations.

Causes of Problems

CBT assumes that negative emotions are linked to an individual's capacity to distort reality in dysfunctional ways, which often results in withdrawal from meaningful activities. The combination of these processes creates a downward depressive spiral that limits the individual's capacity to respond to life challenges in a functional way. Thus, while everyone experiences stressful life events over the course of a lifetime, it is the individual's subjective evaluation and behavioral response to that evaluation that determine whether they experience psychological distress. The interaction between the experience of a stressful event and the individual's perception and response to that event predicts outcome.

Beck's cognitive model identifies three specific factors that disrupt an individual's capacity to perceive and respond to experiences in a functional way. The first is known as the ‘negative or cognitive triad,’ an interactive set of negative or distorted beliefs about the self, experiences, and the future. Depressed persons often believe themselves to be unworthy, deficient, or unlovable and interpret negative life events as their fault or as a result of their own inadequacy. Thus, the person who does not get an expected promotion at work might attribute this to the belief ‘I am mediocre,’ rather than considering alternative explanations (e.g., ‘The person who got the promotion had more seniority’). In the same way, beliefs about life events and the future will filter the way an individual interprets his or her experience.

The second factor in Beck's model is maladaptive ‘schema.’ Schemas are stable organizational patterns of thought that form the basic framework for classifying and evaluating experience. These schemas reflect a kind of world view represented by a set of underlying beliefs about self and others. Often these beliefs, while automatic, are implicit and out of the awareness of the person. Maladaptive schemas impair the individual's ability to objectively evaluate interactions and events, foster a persistent negative response bias, and frequently result in negative affective and behavioral symptoms. For example, following the death of a spouse, the person who holds the schema ‘I must have someone to take care of me,’ would be likely to endorse such statements as ‘I will never be safe (loved, cared for) again.’ This schema pushes the individual into an unrealistic appraisal of the situation and to a negative appraisal of self, experience, and the future.

The third factor in Beck's model is that maladaptive schemas lead to errors in information processing and logical thinking. In particular, identifiable patterns in cognitive errors are common and include (1) selective attention (focusing on some details while ignoring other relevant facts of the situation), (2) overgeneralization (assuming that the outcome of one incident will occur in all situations), (3) arbitrary inference (drawing a conclusion in the absence of evidence), (4) magnification or minimization (distorting the importance or significance of a single event), (5) personalization (assuming automatically that external events relate to oneself), (6) ‘all-or-none’ thinking (categorizing continuous experiences as dichotomous extremes, such as good or bad, loved or hated).

The consequence of these dysfunctional cognitive processes is often a behavioral response that removes the individual from active engagement in enjoyable or meaningful activities. The loss of enjoyable activity contributes to the downward spiral of depression and makes it difficult for the individual to recover from a challenging or stressful life event.

11.09.2 Disorder-Specific Versus Transdiagnostic Approaches

Classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (fifth Edition, DSM-5, American Psychiatric Association, APA, 2013) and International Classification of Diseases (11th edition, World Health Organization, 2019), provide frameworks for conceptualizing mental disorders based on co-occurring constellations of symptoms. As evidence has accumulated for distinctions between phenotypes, expert committees have included new disorders and subtypes into the nomenclature. This process has resulted in an increasing number of mental disorders over time, along with disorder-specific diagnostic assessment tools that aim to optimize diagnostic reliability (Barlow et al., 2014). An immense body of knowledge has been gained from disorder-specific theories, and these have led to efficacious and effective treatments for their respective disorders (Hofmann et al., 2012).

Theorists have extended established models to new disorders as they are “born”. For example, the cognitive model, which was initially applied to depression (Beck et al., 1979), was extended to most anxiety and related disorders (e.g., Clark, 1986; Clark and Wells, 1995; Salkovskis, 1985; Rapee and Heimberg, 1997). Diagnosis-specific models describe unique cognitive content (e.g., cognitive triad for depression, catastrophic misappraisals of physical sensations for panic disorder, fear of negative evaluation for social anxiety disorder, responsibility appraisals for OCD) and behaviors (e.g., withdrawal, avoidance, safety behaviors) that are considered fundamental to disorder maintenance. An important side-effect from parallel theorizing and treatment development for different disorders has been the identification of numerous commonalities. For example, in one way or another, all evidence-supported treatments aim to increase patients' understanding of the relationship between cognitions and behaviors, although the specific content may differ across disorders. When clients understand the common functional relationship between cognitions and behaviors then they should be better-equipped to modify their behavior and challenge their dysfunctional beliefs regardless of the nature of their beliefs, behaviors, or diagnostic profile. Learning how to flexibly apply the empiricism inherent in cognitive therapy is, therefore, critical for clients to recover from a range of clinical problems, stay recovered, and generalize the principles to comorbid clinical problems.

As theorists, clinical researchers, and clinicians began to recognize the substantial commonalities across mental disorders and their treatments, transdiagnostic approaches to understanding etiology, maintenance, and change emerged. To be sure, disorder-specific and transdiagnostic approaches both aim to identify commonalities across individuals, either with respect to the same disorder in the case of disorder-specific approaches (e.g., major depression, schizophrenia), or within (e.g., anxiety disorders, affective disorders, eating disorders, psychosis) or between (e.g., anxiety and depressive disorders) classes of disorders in the case of transdiagnostic approaches. The distinction between disorder-specific and transdiagnostic approaches is, therefore, a relative one determined by the degree of granularity. Mansell et al. (2009) proposed criteria for transdiagnostic processes, requiring that they be present in a minimum of four disorders, as well as present in both clinical and nonclinical samples. The requirement for the process to be present in clinical and non-clinical samples is consistent with a dimensional approach to psychopathology (Kozak and Cuthbert, 2016), which lends itself well to transdiagnostic approaches. From this perspective, different phenotypes represent differential calibrations across a range of key dimensions, rather than assuming a diagnostic dichotomy whereby a dimension is present or not. However, it is unclear why four disorders was determined as the cutoff for a transdiagnostic process and, indeed, the authors acknowledged that this was arbitrary (Mansell et al., 2009, p. 9). Presumably a mechanism associated with two separable disorders, particularly if they derive from different classes of mental disorder (e.g., anxiety and affective, or anxiety and eating), could also be considered transdiagnostic.