Cognitive (or Neurotic) Styles

The notion of cognitive styles originated, in my understanding, with Shapiro's book "Neurotic Styles." Shapiro was a contemporary of Beck in the movement from psychoanalytic thought to cognitive theory. You can easily pick up in this early cognitive work the lingering analytic terminology (ie., neurotic). Many would argue that while Beck disagreed with some analytic assertions, namely not finding the primary role of aggression in depression during his dissertation, he did not reject psychodynamic foundations. However, these dynamic foundations were lost on many of his followers (possibly seeing cognitive theory as standalone rather than stemming from or integrable with psychodynamic theories - I believe Beck simply determined not to repeat what was already established elsewhere in literature).

Conversely, my reading of Shapiro was that he saw his assertions in Neurotic Styles to be a counterpoint to ego psychological focus on defense mechanisms; Shapiro posits that there is an underlying cognitive (neurotic) style that influences the development or adoption of defensive constellations - a fundamental trait akin to Jung's notion of temperament (introversion and extroversion). This could possibly imply that, if cognitive styles were fundamental we don't need to identify defenses to understand the character. The two constructs are, however, compatible as demonstrated on the graphic above, and also both finding a valuable place in Millon's Personality Disorders In Modern Life.

In Practice: Conceptualization

I personally find it useful to loosely locate where my client sits in the above diagram, or at least along the continuum from intellectualized to emotive. In my setting - an outpatient private practice in a northern city (Pittsburgh) that draws in a lot of high-functioning intellectuals (tech, medicine, and colleges) - we see a lot of people who are on the intellectual side of the continuum, but may not have OCPD (obsessive compulsive personality disorders - the most prevalent personality disorder according to most sources), nor excessively overusing the full constellation of those defenses. However, it is useful to explain this to those individuals in a psychoeducational manner, and with the notion of a psychodynamic life narrative in mind: "many people who are successful like you academically and in a technical career might have what we call an intellectual cognitive style, or are more self-controlled. This probably made it possible to have your success, but also poses challenges in certain emotional areas..."

As Related to DBT Behavior Chain Analysis (BCA)

Working in the Acute Trauma and Borderline Personality Disorders inpatient hospital program at UPMC's Western Psychiatric Hospital, I completed Behavior Chain Analyses (BCA), with nearly every new patient. With the notion of cognitive styles in mind, I noticed many patients consistently overlooking, as if having a blindness to a portion of their psychological experience, either emotive or intellectual/factual (thoughts) cognitive content. Some patients would list a chain of thoughts, actions and events, noting only anxiety in terms of emotions. Others would seem to be tossed into the unpredictable whelms of a sea of emotions with little insight into the thoughts, actions and events that influenced them. And yet others, most interestingly, turn in sparse or completely blank papers - they often literally said "my friends say I am in denial." These individuals also experienced (by history and often over the course of the hospitalization) psychotic features and brief psychotic episodes.

I tended to tailor my interventions based upon this. First, I would ask them to try to fill in the missing content (thoughts for the emotive folks and emotions for the intellectualizers). Second, is something people often don't find to be intuitive: CBT for the emotive folks and emotion-focused interventions for people who intellectualize. Frequently, I hear recommendations that "he/she is very intellectual/cognitive, so they would do well with CBT," but to me, that is colluding with, enabling or encouraging the already-trophied (over valued or overused) cognitive style that doesn't need extra help. What they need is help refocusing on, or being mindful of, otherwise out of sight emotional experiences and tolerating them. Tolerating emotions for someone avoidant of them could be thought of as exposure therapy for affect phobia - we would discuss the analogy of dipping your toe in a hot tub and it feels like it will burn, but within moments you can adjust your entire body and it feels great. We call this sitting with the emotion.

CBT information processing model

For traditional CBT, the most iconic intervention is the thought record. While thought records are often displayed linearly, the underlying information processing model is cyclical, as displayed in the graphic to the right. The most common question that I hear is, "ok great, but how do I know when to use the thought record, and where do I start?" My answer is always, "when you feel a painful emotions - start by writing down the emotion, then what triggered it (the event), and try to fill in your interpretation of the event - the thought - that shapes your emotional reaction. On the next line down, write a different but plausible thought or interpretation of the event. Is the emotion the same? What about how you would behave and the consequence or outcome?" In other words, CBT can lend itself to people who are influenced by strong emotions, but frequently unaware of the thought - that's why they are called "automatic thoughts." This exercise helps us build awareness of the thoughts and the skills to access that insight in real time.

Emotion focused work can often be helpful for the over-controlled or intellectual client. I might invite the client to "sit" in the emotion, offering the hot-tub analogy. They may need help identifying the primary emotion and distinguishing it from secondary emotions (frequently anxiety being the conscious one, or for male clients, anger masking hurt). After they tell the story, explore any range of possible emotions, "how do you imagine someone else might feel given the same experience?", or utilizing your own emotional barometer or countertransference in a manner that validates feelings you suspect are occurring: "I can imagine feeling..."

Somatic exercises are quit helpful here: "where do you feel it in your body?", "Can you put words to that feeling - if it were a sentence, what would it say?", using a somatic bridge: "Can you recall a previous or earliest time you felt that way?", and making sure it isn't a surface but deep experience if the visceral sensation might only be skin or muscle deep: "lets go going further down - anything else deeper in your body?"

The somatic bridge exercise can often unearth very emotional or traumatic experiences that laid the foundation for the emotional schemes we are exploring in the here and now. A following blog article with pick up where we are leaving off - a few ideas for processing these emotions.