Per-Hour Learning Potential / Utility: ★★★★★★★ (7/7)
Readability: ★★★★★★★ (7/7)
Challenge Level: 3/5 (Intermediate) | ~360 pages ex-notes
Blurb/Description: Dr. Judith Beck, daughter of cognitive behavioral therapy pioneer Aaron Beck, writes a definitive, usable, and relatable book on how to identify and replace maladaptive core beliefs and automatic thoughts that lead to unwanted emotions or behavior. If you want a handbook for how to make mental models an automatic thought process, this is it.
Summary: I’ve long considered writing a post titled “How Depression and Anxiety Made Me A Better Investor.” I spent about a decade of my life, from my preteens to my early 20s, being anywhere from mildly to severely depressed and anxious.
Part of this, as I discuss elsewhere, was exacerbated by sleep deprivation (see Dr. Matthew Walker’s critically important “Why We Sleep” – Sleep review + notes), but much of it was related to an inappropriately-calibrated schema: i.e., my filter for perceiving and processing the world was out of focus.
While many people stay below the “ critical threshold” of their emotions and cognitions not causing direct, unbearable disruption to their life, I found myself well above that threshold, which forced me to do something about it.
Dan Harris found the answer in meditation, but as I discuss in the notes on 10% Happier (10H review + notes), I found my answer in self-administered cognitive behavioral therapy, which I got to via following the agency focused lines of thinking in Shawn Achor’s ‘The Happiness Advantage” (THA review + notes) and Stephen Covey’s ‘The 7 Habits of Highly Effective People” (7H review + notes).
Surprisingly, CBT ended up helping me with way more than just depression and anxiety. Why? As Dr. Beck explains in the book:Dysfunctional beliefs can be unlearned, and more reality-based and functional new beliefs can be developed. - Dr. Judith Beck Click To Tweet
CBT, simply put, is one way of, as Philip Tetlock speculates in Superforecasting ( SF review + notes), training your automatic “System 1” to error-correct and automatically interpret the world more accurately.
I’ve never actually seen a therapist (you can implement CBT yourself, although I imagine a professional trained in it would dramatically accelerate the process.) Somewhat surprisingly, this is the first time I’ve ever read a book on CBT (I’d mostly read stuff on the internet before).
It blew me away – it not only provides a very concise and useful explanation of the (altogether-too-infrequently-discussed) concept of schema, but it also provides an array of very useful tools for evaluating and replacing beliefs in your schema and communicating with empathy..
Highlights: Like Thaler’s “Misbehaving” (M review + notes), CBT is a twofer: not only do you get a lot of important psychology theory, but you also get to relate to the book from two perspectives: the therapist’s and the patient’s. In addition to helping you evaluate your own thoughts and beliefs and replace them with more adaptive ones, this book will help you do the same with your friends and family.
The fictional / anonymized “transcripts” of interaction between patient and therapist do a phenomenal job of putting the concepts and techniques into action, as well as being a wonderful practical example of how to communicate empathetically (in a much more realistic / non-promotional way than Carnegie).
The book is also very scientific and mental models-oriented, showing how phenomena like feedback, confirmation bias, contrast bias, and habit can lead to negative outcomes – but also how they can be flipped around and used in our favor.
Lowlights: The book is a little bit repetitive in the sense that most of the same techniques apply to evaluating “core beliefs” as “automatic thoughts” so at some point you will probably get the point. Also, lay readers can/should skip some of the chapters that are more pertinent to actual therapists (see “Reading Tips.”)
Also, readers who haven’t dealt with depression/anxiety might find the constant focus on these two topics to be somewhat tiresome… again, I think most of the book works just as well if you entirely remove the “mental health” angle and simply think of CBT as a set of tools and techniques for
evaluating the world in a more adaptive way.
Mental Model / ART Thinking Points: schema, cognition vs. intuition, cognitive behavioral therapy,nonlinearity, overconfidence, probabilistic thinking, contrast bias, empathy, storytelling, scientific thinking, trait adaptivity, feedback, empathy, a/b testing, utility, memory, habit, structural problem solving, margin of safety, base rates, bottleneck, memory, incentives, activation energy, Bayesian reasoning
You should buy a copy of Cognitive Behavior Therapy if: you want a practical, well-considered, empirically-validated step-by-step guidebook to improving your automatic “System 1” response to the world, as well as a phenomenal practical guide to empathetic communication.
Reading Tips: For lay readers (i.e. most of us who don’t want to become a professional therapist), you can get away with reading only 200 pages of this book and get 95% of the value.
I would recommend reading the foreword/preface and Chapters 1 – 6 and 8 – 13, skipping Chapter 7 (which is more about structuring therapy sessions and somewhat less useful in our context). If you’ve gotten the point by then (or even before the end), stop reading! As Thaler quips, to do otherwise would be “Misbehaving.”
If you’re still intrigued, there’s some additional value in chapters 14 and 15, but on my own reread in the future, I won’t bother with anything from 16 through the end, which are also more targeted toward professional therapists or counseling students, and not really helpful to a lay audience.
Philip Tetlock’s Superforecasting (SF review + notes). There are a ton of parallels between the CBT “worldview” and the thought process used by ordinary people who became superstar predictors in Tetlock’s research; I think the two books complement each other nicely by analyzing many similar mental processes in very different contexts.
Brene Brown’s Daring Greatly (DG review + notes). Empathy and self-awareness are non-intuitive skills, especially for young males (i.e. the sort of people who tend to be investors), and I view them as critical to not only being a good person and living a fulfilling life, but also to being an investor capable of separating from the noise and making good decisions under all circumstances.
Cass Sunstein and Richard Thaler’s Nudge (Ndge review + notes). CBT can be viewed as “ structural problem solving” in the sense that you’re lowering the activation energy to make good decisions. Nudge follows a similar premise in a totally different context (corporate and public policy). It makes for fascinating reading on cognitive biases, and readers will pick up a bunch of tricks to use in their own lives.
Dan Harris’s 10% Happier (10H review + notes). I’ve never been able to get past the first step of meditation, and I conceptually prefer the more active/aggressive CBT approach of identifying bad thoughts and ripping them out and replacing them with useful ones to the passive approach of simply observing thoughts… I view cognition as my greatest strength and I’m at my best when I’m thinking, not when I’m actively trying to avoid thinking.
Nonetheless, in the interests of not being a man-with-a-hammer, I think that many readers might benefit from meditation over CBT, or a combination of meditation and CBT: Harris’s book is a lighthearted, open/honest, non-granola-y look at meditation from a secular/skeptical perspective (that comes away very positive). It’s worth checking out and is enjoyable to read even if you end up not finding meditation useful.
Reread Value: 4/5 (Very High)
More Detailed Notes + Analysis (SPOILERS BELOW):
IMPORTANT: the below commentary DOES NOT SUBSTITUTE for READING THE BOOK. Full stop. This commentary is NOT a comprehensive summary of the lessons of the book, or intended to be comprehensive. It was primarily created for my own personal reference.
Much of the below will be utterly incomprehensible if you have not read the book, or if you do not have the book on hand to reference. Even if it was comprehensive, you would be depriving yourself of the vast majority of the learning opportunity by only reading the “Cliff Notes.” Do so at your own peril.
I provide these notes and analysis for five use cases. First, they may help you decide which books you should put on your shelf, based on a quick review of some of the ideas discussed.
Second, as I discuss in the memory mental model, time-delayed re-encoding strengthens memory, and notes can also serve as a “cue” to enhance recall. However, taking notes is a time consuming process that many busy students and professionals opt out of, so hopefully these notes can serve as a starting point to which you can append your own thoughts, marginalia, insights, etc.
Third, perhaps most importantly of all, I contextualize authors’ points with points from other books that either serve to strengthen, or weaken, the arguments made. I also point out how specific examples tie in to specific mental models, which you are encouraged to read, thereby enriching your understanding and accelerating your learning. Combining two and three, I recommend that you read these notes while the book’s still fresh in your mind – after a few days, perhaps.
Fourth, they will hopefully serve as a “discovery mechanism” for further related reading.
Fifth and finally, they will hopefully serve as an index for you to return to at a future point in time, to identify sections of the book worth rereading to help you better address current challenges and opportunities in your life – or to reinterpret and reimagine elements of the book in a light you didn’t see previously because you weren’t familiar with all the other models or books discussed in the third use case.
Page ix: Cognitive behavioral therapy, or CBT, is based on the premise that depression and anxiety have at their core a:
“systematic bias in the way the patients interpreted particular experiences.”
Training patients to notice these biased interpretations and replace them with more adaptive ones leads to an:
“almost immediate lessening of the symptoms.”
In other words, CBT is a learnable, repeatable process for modifying our schema and thereby modifying our intuitition (System 1) to achieve results similar to those discussed by Philip Tetlock on page 236 of Superforecasting (SF review + notes):
“My sense is that some superforecasters are so well practiced in System 2 corrections – such as stepping back to take the outside view– that these techniques have become habitual. In effect, they are now part of their System 1.”
The often-lauded Danny Kahneman has done great research, but holds the fundamentally incorrect and maladaptive view that we can’t modify the biases of our System 1 (which is one of the major reasons, among others, that Thinking Fast and Slow is a terrible book – see TFS review.)
In contrast, Beck’s Cognitive Behavior Therapy not only demonstrates the opposite, but provides a concrete set of steps and tools for accomplishing it.
While the focus of the book (naturally) is on the maladaptive thoughts and beliefs that can lead to or exacerbate anxiety and depression, the steps and tools outlined are equally useful for evaluating and replacing other maladaptive beliefs and cognitive biases.
For example, from my personal experience, the CBT process can be useful for dealing with overconfidence, probabilistic thinking ( counterfactuals), contrast bias, improving our skills at empathy, avoiding storytelling, and a host of other applications.
Page 1: Here’s an example of scientific thinking at its finest – cognitive therapy was more or less invented/discovered C(B)T in the 1950s/1960s by Dr. Aaron Beck, an assistant professor of psychiatry at the University of Pennsylvania.
Dr. Beck was a practicing psychoanalyst (i.e., Freudian) and he set out to scientifically prove its efficacy… his daughter Dr. Judith Beck is now writing this book.
… instead, he proved the opposite. And, to his immense credit, instead of succumbing to confirmation bias as so many would have – see, for example, many classical economists in Richard Thaler’s Misbehaving ( M review + notes) for an example of “bad science” – Beck kept an open mind and in the process developed a powerful therapeutic intervention.
See also Dr. Matthew Walker’s hilarious deconstruction of Freudian psychoanalytic dream interpretation in “Why We Sleep” (Sleep review + notes), as well as Tavris/Aronson’s mention in “Mistakes were Made (but not by me)” (MwM review + notes). Tavris/Aronson note “what a terrific theory!” given that Freudian psychoanalysis, like conspiracy theories, is set up so it can’t be disproved. (On the latter topic, see Megan McArdle’s “The Up Side of Down” – UpD review + notes – for a hilarious take.)
Page 3: Core to CBT is the “cognitive model,” which suggests that dysfunctional thinking/beliefs lead to negative emotions and behavior. By changing our basic beliefs, we can change our schema (as we’ll get to in a second), and thereby interpret and respond to the world in a more effective, accurate, and adaptive manner.
Here, Beck uses the example of “I am a mistake” vs. “I made a mistake,” as similarly discussed by Brene Brown in I Thought It Was Just Me (but it isn’t) (ITWJM review). This is the core idea of the growth mindset, which research by psychologist Carol Dweck has demonstrated is a critical driver of success. (Dweck’s book “Mindset” ( Mndst review + notes) isn’t great, but her research is nonetheless very important.)
Page 4B, 5, 6: CBT has been proven to be effective in treating a wide variety of physical and mental health problems, with different flavors for depression, anxiety, etc. While there is no scientific basis for psychoanalysis, CBT is as effective as antidepressants under certain circumstances. (Disclaimer: I am not a doctor nor a mental health practitioner; this is not medical advice.)
In Walker’s “ Why We Sleep” ( Sleep review + notes), the idea of “CBT-I” – i.e., CBT for insomnia – is even explored, and is apparently, similar to CBT for anxiety/depression, as or more effective than medication with no side effects, such that it’s considered a front-line treatment.
Page 7: CBT involves examining the feedback mechanism that leads to the creation and perpetuation of maladaptive thoughts and behaviors – as the book will discuss, thanks to confirmation bias and a number of other factors, maladaptive thoughts lead to maladaptivebehaviors which, perversely, reinforce those maladaptive thoughts.
By modifying the thoughts and behaviors, we can turn that cycle around and create a positivelyreinforcing loop for more adaptive thoughts.
Of course, to practice CBT, you need to develop your empathy skills to understand the world from another person’s point of view.
Page 8: Unlike some other types of therapy, CBT is heavily goal-oriented and utility focused: there is a:
“strong focus on current problems and on specific situations that are distressing.”
The process of modifying beliefs leans on probabilistic thinking as well as a/b testing – it’s very scientific, in the sense of exposing ideas to the real world.
Page 9: One of the genius steps in CBT, which seems obvious with hindsight bias but I can attest is totally non-obvious beforehand, is coming to the realization that just because you believe something doesn’t mean it’s true. ( Probabilistic thinking.)
“To believe something is to believe that it is true; therefore a reasonable person believes each of his beliefs to be true; yet experience has taught him to expect that some of his beliefs, he knows not which, will turn out to be false.
A reasonable person believes, in short, that each of his beliefs is true and that some of them are false.”
This isn’t even in the sense of political ideology – we’re not talking about gun control, or Israel-Palestine, or a single-payer healthcare system. We’re talking about fairly fundamental and personal beliefs about who we are and how we fit in the world.
CBT also is fairly time-limited, in the sense that a few months is usually sufficient to achieve meaningful improvement.
Page 10: CBT also makes use of habit – session format and thinking processes / assignments are structured in a very repeatable, routinizable way, making it easy for patients to start doing it automatically.
The CBT process involves using Socratic questioning to help patients:
“identify key cognitions and adopt more realistic, adaptive perspectives.”
Changing core beliefs leads to a different set of “automatic thoughts” which leads to a different set of emotions and behaviors.
How is the adaptivity and realism of someone’s thinking evaluated? A person who is depressed, for example, might have the automatic thought upon a friend not returning their call that “oh, they don’t want to talk to me and they don’t like me,” whereas a normal person would be more aware that that is one possibility among many others (for example, they are busy, or a technological error led to them not being notified by their phone.)
Through what Beck calls “collaborative empiricism” – a process of testing the patient’s beliefs against the world relative to counterfactuals, to determine which is more valid or less valid. Scientific thinking.
(Note that there’s inherently a probabilistic element here; the therapist is not looking to make people 100% believe or not believe something, but rather just shift the percentage by which they believe something and its opposite.)
CBT isn’t about convincing people that they’re wrong, but rather about exploring the evidence to see what’s right.
Pages 11B – 12T: Each session starts by checking the patient’s mood and seeing if any problems have come up.
Pages 13B – 14T: One of the great parts of this book is the hands-on demonstration of the techniques via transcripts of discussions with fictional/anonymized patients. Beck often calls out techniques in brackets, i.e. [being collaborative] and [eliciting feedback] – which really enhances the effectiveness of the empathy training as well as the CBT techniques.
Page 14: As mentioned in the review, I’ve never actually seen a professional cognitive behavioral therapist, but one of my friends with a master’s degree in counseling has joked that if the finance thing doesn’t work out, I could be a therapist.
I’ve practiced these skills by helping my friends, but mostly by helping myself: indeed, Beck’s book here notes that:
“your growth as a cognitive behavior therapist will be enhanced if you start applying the tools described in this book to yourself.”
And I’m confident many readers can do the same.
Page 15 – 16: The technique of a “coping card” is an interesting structural problem solving approach. Basically, it’s an index card that provides some helpful thoughts as a reminder to deal with maladaptivethoughts/behaviors.
One of my fund manager friends has done something similar, taping an index card with a brief number of “rules” to each monitor in his office… the rules dictate what to do in certain situations (i.e., check X before you trade, don’t do Y if you’re feeling Z, etc).
It’s somewhere between a checklist and a coping card, but either way, it’s helped him and his team avoid plenty of mistakes.
Page 18 – 19, 20: Beck here provides a nice overview of various ways to display empathy. It’s important to note, as Brene Brown and others do, that empathy isn’t necessarily about validation or agreement with whoever you’re talking to.
Rather, it’s simply displaying sensitivity to their needs, playing back what they’ve said to make sure you fully understand the situation, and providing a perspective that will help them see things more adaptively.
This is a problem often faced by historians – Christopher Browning’s phenomenal “ Ordinary Men” ( OrdM review + notes), a great psychological analysis of some of the average Joes who carried out horrific Holocaust orders, touches on the challenge of seeking to understand human behavior without condoning it.
Similarly, John Lewis Gaddis’s “ The Landscape of History” ( LandH review + notes) touches on this phenomenon, discussing how it’s easy to fall into the trap of evaluating historical events or decisions based on currentcultural norms and scientific knowledge.
Anyway, in a CBT perspective, it is also worth noting (something I’ve found out myself) that empathyisn’t just one tone fits everyone. Beck notes at the bottom of page 20 that due to individual differences, some patients might love a warm/caring approach, while others might be put off by it and view it as too “touchy-feely.”
This is a nice example of a schema bottleneck – one of the most common things I’ve observed is that many people try to follow the “golden rule” of treating other people how you’d want to be treated, but most people are incapable of conceiving that the way someone else wants to be treated is different than the way they want to be treated (even if given explicit feedback).
Thus, good intentions can often be misread: for example, I tend to be very warm and close and caring, which is how I like to be treated, but plenty of people I’ve known view that as overly clingy and prefer some coolness and distance/detachment.
As such, Beck recommends (here and elsewhere) paying attention to patients’ emotional reactions, and frequently seeking feedback.
Page 23: There are tons of parallels between Cognitive Behavior Therapy and Superforecasting ( SF review + notes). Beck’s table here on “guided discovery” – i.e., the process of exploring how valid/ adaptive beliefs are – is very comparable to the thinking process of superforecasters that Tetlock discusses.
The inherent ideas here are probabilism and counterfactuals – how likely is X to be true, and what could be other explanations? There’s also utility: what happens when you believe X? What’s the worst or best or most realistic that could happen if you did Y?
Finally, Beck uses the technique that I thought I came up with on my own, but apparently didn’t: removing yourself from the inside view in favor of the outside view by applying the exact same circumstances that apply to you to a loved friend or family member. Of course, it’s easier to give advice than to take it 🙂
Pages 26B – 27T: Beck here and elsewhere notes that most depressive (and anxious) patients will tend to focus on the negatives and often “catastrophize,” i.e assuming too much margin of safetyand always automatically assuming the worst. Beck notes the process of searching for counterfactuals: guiding patients to notice and evaluate more positive data that contradicts their thoughts and beliefs.
Again, I want to stress that there is really nothing pathology-specific about CBT and the process works equally well if you hae the opposite problem: overconfidence/ overoptimism, or, for example, drawing big conclusions from small sample sizes.
Tetlock discusses the idea of counterfactual thinking, and it’s something I’ve been doing for quite a while now: rather than the standard confirmation bias and storytelling problem of immediately jumping to a conclusion, I find it very helpful to get in the habit – for even small, everyday things – of generating a number of hypotheses and not immediately committing myself to any of them, but rather evaluating the likelihood of each (vaguely and directionally).
In investing, a deep understanding of luck vs. skill has now become a core belief, to the extent that my “automatic thoughts” are very different than they used to be. When a stock price moves, I don’t assume anything… when I get a very favorable outcome on a thesis where not enough time has passed to really prove out my fundamental expectations, I chalk it up to luck rather than skill.
Page 27B: Beck also here notes the flaws of memory: she notes that:Patients tend to forget much of what occurs in therapy sessions. - Dr. Judith Beck, on why notes and homework are an important element of CBT. Click To Tweet
So the smart thing for a therapist to do is to make sure homework assignments are written down.
Page 30 – 31: Beck here goes deeper into the cognitive model, noting that upon the occurrence of a situation or event, people have automatic thoughts that lead to a reaction. This can be behavioral (an action), physiological (heart rate / breathing / etc), or emotional (sadness, anger).
She notes, importantly, that situations don’t determine how people feel – instead, it’s how someone construes a situation. See stress / humor / gratitude.
This is a relatively common but profoundly insightful and unintuitive worldview: see also Shawn Achor’s “The Happiness Advantage” (THA review + notes) for research on the topic as well as extensive practical methods for implementing it in your own life as well as those of people you care about.
One of his core ideologies is sourced from Viktor Frankl’s observations during the Holocaust on how some people were able to cope with horrifying circumstances:Between stimulus and response, we have the power to choose. - Stephen Covey, from Viktor Frankl Click To Tweet
Beck goes meta and points out to readers that they likely have two levels of thinking while reading this book: one level on the information, but another level interpreting the information in some way that’s more automatic than considered (which could range from “this is stupid” to “this is awesome” depending on where you’re coming from.)
It’s not so important at the moment what those thoughts are: what’s important, Beck notes, is that you might be “barely aware” of the automatic thoughts, and if you are aware of them, “you most likely accept them uncritically […] you don’t even think of questioning them.”
The solution is surprisingly simple: first, always ask yourself “what am I thinking and why,” and second, ask yourself if that’s reasonable. (I’m paraphrasing the entire book here.)
Pages 32 – 33, 35 – 37: Beck goes into the concept of schema here.
While the formal psychological definition is a little looser than the informal definition I use, the idea remains the same: our set of “core beliefs” add up to form something equivalent to a lens between us and the world. Beck here notes the idea of confirmation bias: we have a tendency to confirm what is already in our schema, and a tendency to filter out (or not even notice) information that doesn’t fit in with our schema.
The good news, Beck notes, is that:
“dysfunctional beliefs can be unlearned, and more reality-based and functional new beliefs can be developed”
via CBT techniques. Core beliefs (“I’m an incompetent person”) lead to intermediate beliefs (“this class is too hard for me”) which leads to automatic thoughts (“why bother trying to read the book”).
Beck notes that:
“the quickest way to help patients feel better and behare more adaptively”
“once they do so, patients will tend to interpret future situations or problems in a more constructive way.”
“Science is a form of arrogance control.”
Again, this rings very similar to Tetlock’s Superforecasting, wherein a specific process of thinking proved to be more important to prediction than access to all the data or expertise on the subject matter. It’s also, essentially, the core of the mental models approach: rationality is worth 50 points of IQ, etc.
That said, Beck notes that attempting to modify core beliefs right off the bat can lead to resistance… she doesn’t go into it, but I think there’s a bit of contrast bias here, specifically in the sense of “just noticeable differences” as discussed by Thaler in Misbehaving (M review + notes), and Tavris/Aronson in Mistakes were Made (but not by me) (MwM review + notes).
Beck notes that it’s:
“easier for patients to recognize the distortion in their specific thoughts than in their broad understandings of themselves”
so working on the “superficial” level of cognition makes patients more likely/willing to work on the deeper levels, similar to the “pyramid” of self-justification discussed by Tavris/Aronson.
Again, the core idea here is to separate truth from thought, and to modify thinking to be more realistic or adaptive.There’s a scientific name for people with an especially accurate perception of how talented, attractive, and popular they are – we call them clinically depressed. - Megan McArdle Click To Tweet
Indeed, intellectual humility is dose-dependent. There’s such a thing as too much.
If you expect an indefinite future ruled by randomness, you’ll give up on trying to master it.
Page 38: There’s a lot of useful material on pages 38 – 39 that I want to return to… it’s basically a more complex version of the simplified model presented above.
Page 41: Yes, your childhood matters…
Page 42: Beck notes that intermediate beliefs – “attitudes, rules, and assumptions” – are easier to modify.
Page 52: Here is a great example of probabilistic thinking: Beck (as therapist, talking to a patient) notes that a thought should be evaluated as “100% true, 0% true, or someplace in the middle.”
I think this probabilistic approach also works for belief modification because, again, it exploits the concept of contrast bias / “just noticeable differences.” It’s probably harder to go from “I’m incompetent” to “I’m awesome” in one step, but it’s much easier to go from “there is 0% chance that studying for this specific test would help” to “there is a 20% chance that studying for this specific test would help.” And so on and so forth…
Page 53: Beck notes that it’s important to ask the patients if there’s anything under the surface they don’t want to talk about. (They don’t have to talk about it.)
Page 55: Again to the above, CBT is essentially a process of compounding – Beck (as therapist) notes that:People get better by making small changes in their thinking and behavior every day. - Dr. Judith Beck Click To Tweet
Page 57: There is still some “your childhood” stuff here – it can be helpful to evaluate why you hold the beliefs you do, and how you got to where you are today.
Pages 64 – 65: Nice example here of utility and 80/20 – CBT is not focused on delving into every little issue, but rather solving the major issues causing major problems. This differentiates CBT from some other forms of therapy; as Shawn Achor quipped in his famous TED Talk:
“If you fall below the average, then psychologists get thrilled, because that means you’re either depressed, or you have a disorder, or hopefully both.
We’re hoping for both because our business model is if you come into a therapy session with one problem, we want you to leave knowing you have ten, so you’ll keep coming back over and over again!”
There’s also a bit of the Shawn Achor gratitude technique here… depressed patients tend to only notice bad stuff; it can be helpful to notice good stuff too. (Of course, this works equally well via inversion: as an investor, when things are going really well, you should probably take the time to notice things that could use improvement.)
There’s a lot of research in that book touching on anxiety/depression and other mental health issues, as well as more garden-variety everyday stress and emotional control. Walker notes that poor sleep in adolescents is implicated as a causative factor of mental health issues (though of course it’s multicausal).
Moreover, even modest sleep deprivation can exacerbate depression and anxiety. A lot of the processes discussed by Beck implicitly rely on the prefrontal cortex (the logical, rational part of our brain) being able to control the amygdala (the emotional part of our brain).
This relationship between amygdala and prefrontal cortex is explored wonderfully in Laurence Gonzales’s “Deep Survival” (DpSv review + notes) in the context of why people survive or perish in life-or-death situations. Gonzales compares the amygdala to his overzealous chocolate Lab, who barks at anything that comes to the door.
Gonzales notes that information hits the amygdala, which screens for danger, before it hits the neocortex. He quips that “Like Lucy, the amygdala isn’t very bright,” but it is powerful and responds in an emergency.
We cannot rein in our atavistic impulses – too much emotional gas pedal (amygdala) and not enough regulatory brake (prefrontal cortex).
Without the rational control given to us each night by sleep, we’re not on a neurological – and hence emotional – even keel.”
I definitely observed this in my own personal life: being forced into a lark schedule by my job meant that I was getting six hours of sleep or less on weeknights, and trying to make it up on the weekends (which Walker notes doesn’t work).
Setting aside the physical symptoms (chronic psychosomatic muscle pain, exhaustion, upset stomach) and the performance symptoms (limited ability to focus early in the day, memory loss), I also had near-constant anxiety, episodic depression, and occasional panic attacks.
When I quit my job and started sleeping nine hours a night, many of these symptoms abated partially or entirely (with CBT taking care of the rest).
Pages 66 – 67: Beck here uses the classic “tinted glasses” metaphor for schema. Depression is like “eyeglasses covered with black paint.” She also notes that “normalizing” can be a powerful tool (see also Brene Brown as well here).
CBT “homework” involves reminders to think more adaptively, behave more adaptively, and to be more mindful of automatic thoughts.
Page 69: CBT involves setting and achieving specific, concrete goals.
Page 72: Beck (in therapist mode) asks her patient to play back what she’s learned about the relationship between thoughts and feelings… then Beck reinforces the idea that thoughts aren’t always accurate, and we can help ourselves via counterfactual/ probabilistic thinking.
See also Shawn Achor’s aforementioned ‘The Happiness Advantage” (THA review + notes), or Sunstein/Thaler in Nudge (Ndge review + notes) on activation energy, particularly on page 72 with the Yale vaccine example, but also pretty much everywhere else in the book.
Page 83: One of the core ideas here is “behavioral experiments” – essentially, a/b testing new behaviors. In this case, Beck advises her depressed client to spend some time with friends to see if it’s actually going to be as draining as she thinks it will… or if it might actually be fun.
Testing more complicated behaviors with less immediate feedback, of course, isn’t quite as easy – but this technique is applicable for a whole lot of things. For example, Shawn Achor recommends reading less news and Cal Newport recommends staying off social media… I’ve done both (the latter before I’d ever heard of Newport) and pretty quickly figured out that I was better off without both of them. (See Newport’s “ Deep Work” – DpWk review + notes).
The nice thing is that most of these experiments are pretty costless (i.e. opportunity costs): what’s the worst that can happen if you cut back on reading news or going on social media for a few weeks or a month? Nothing.
Page 85: Here’s a nice example of pre-emptive structural problem solving: Beck has her client think through how her client might feel if she asked her friends to hang out and said no… and helped her find the more adaptive way of thinking about it beforehand.
Page 97: Again on memory: Beck notes patient ratings are more accurate when recorded right after an activity rather than later on.
Page 98: One of the helpful elements of writing down predictions about how much energy something will take, and how enjoyable it will or won’t be, is that it eliminates hindsight bias and faulty thinking… in this case, Beck helps her client discover that she’s not great at predicting how things will make her feel, which is evidence in favor of adopting more adaptive beliefs.
Page 103: Another example of feedback: Beck plays back the patient’s words in a way that reinforces the cognitive model.
Page 106: An interesting note here about interrupting patients to keep the session on track: it’s important to take the time to briefly identify issues and prioritize them rather than just going into whatever comes to mind.
Kind of an interesting parallel between this and automatic thoughts… you shouldn’t just go with your first thought. You should go with your best thought!
Page 108: Unsurprisingly, Beck notes that if you don’t review patients’ homework, they won’t do it… 🙂
Page 118: Using someone’s own words rather than paraphrasing can be powerful…
Page 125: Back to interrupting: if they don’t seem to like it, apologize and modify your behavior. This is, again, a great example of empathy – as discussed elsewhere – Covey and Mistakes were Made, etc – it’s important to admit your mistakes, and people love hearing “I’m sorry.”
If certain patients are resistant to, for example, filling out forms, you can invoke reason-respecting tendency and a la Carnegie, present it as being in the patient’s best interest… it’s best to simply not contradict what the patient is saying. And if the patient really doesn’t want to do it, don’t make them.
Pages 129B – 130T: More Carnegie-esque technique here: offer patients a choice, but make it clear what the consequences for each are. I.e. “we can do it your way, but then we won’t be able to do X, or we can do it the other way, and be able to do X.”
Page 132: this is a nice example of the “ disaggregation/ MECE” stuff I discuss in the notes to Superforecasting. When problems seem overwhelming, one way to address them is one step at a time – how you eat an elephant, etc.
Back to Tetlock’s idea of people embedding System 2 thinking in their System 1, Beck makes much the same point: she notes that we all have automatic thoughts (whether or not we have anxiety/depression), and becoming aware of these thoughts helps us to:
“automatically do a reality check”
“spontaneously (i.e. without conscious awareness) respond to the thought in a productive way.”
Habit and cognition vs. intuition. It is bizarre and irredeemable that a psychologist of Kahneman’s stature wouldn’t believe or understand this… because it’s so obviously true, and (given the research on CBT) dramatically empirically validated.
Page 139: Beck posits that automatic thoughts should be evaluated relative to both validity and utility.
Page 143: Here is a nice list of techniques for eliciting automatic thoughts, including inversion, phrasing the question differently, asking for meaning, asking for feelings and role-playing, etc. Beck ensues to provide some great hands-on examples.
Page 148: Beck here notes that patients often don’t know which of their many issues are the worst. She posits having them hypothetically pretend each of them are solved and see how they feel.
I actually have a little bit of a different take here – not that I disagree with her technique – but I think that sometimes, some of the biggest-impact situations are the hardest to solve. For example, drama with family/friends, challenges at work, etc.
I’ve found (completely anecdotally and unempirically) that stress is an exponential function that displays lollapalooza effects – so, for example, if I haven’t slept well (3 stress units) and I’m not getting along with someone close to me (3 stress units) and I have more to do than I have time for (3stress units), it’s not like I have 3 + 3 + 3 = 9 stress units. It’s more like 3 x 3 x 3 = 27 stress units…
Page 157: Beck with an unintentional quote on the mental models approach.People make predictable errors in their thinking. You teach |people| to identify their dysfunctional thinking, then to evaluate and modify it. - Dr. Judith Beck Click To Tweet
Note that the longer version in the book included “psychological disorders” and the second bracket was “patients” rather than people. But the quote works just as well this way!
Page 158: Beck here notes the painful, schema-altering nature of intense negative emotion. Beck notes that it’s important to empathize with, rather than dismiss, people’s emotions… een if they seem irrational.
Page 160: There is a difference between ideas and feelings.
Page 164: Here’s another little quibble with Beck: she uses a seemingly linear 0 – 100 scale for delineating “not sad at all” or “the saddest I could ever be.”
I think sadness is nonlinear… a bit like the Richter scale, it would need to be theoretically logarithmic, because otherwise you’d have a bunch of stuff clustered around zero and it wouldn’t be a useful scale. See Geoffrey West’s “Scale” (Scale review + notes) on this topic of logarithmic graphs
“The saddest I could ever be” is perhaps an exercise in catastrophizing, but you would basically need to take a country song and add nuclear war and the death of everyone you love and a world without chocolate, coffee, or Coca-Cola… and then compared to that, going through a bad breakup is, like, a 2 out of 100.
The scale makes much more sense if it’s viewed logarithmically rather than percentages, similar to decibels…
But this is probably too much math for the average psychiatric patient, and I’m sure her approach works perfectly fine in the real world! Just a theoretical note.
Pages 170 – 172!: Some important stuff here. Beck notes that most maladaptive thoughts aren’t completely false and it’s important to not directly challenge them, but rather to engage in the “collaborative empiricism” discussed earlier… helping people explore whether or not their thoughts are valid through questioning and testing. Probabilistic thinking and scientific thinking.
Beck provides some helpful tips, such as examining validity, counterfactuals, decatastrophizing, distancing, etc. Dan Harris, meditation advocate extraordinaire, also notes in “ 10% Happier” – 10H review + notes – that he found decatastrophizing helpful, in addition to meditation.
Patients are encouraged to evaluate the utility of certain thoughts and behaviors, to examine the evidence in favor of and against, and to see what they’d tell a friend in the same situation.
It’s worth noting that this a form of qualitative/implicit Bayesian reasoning – you have a “prior” (an existing core belief or automatic thought), and you’re going out and finding some evidence, and evaluating (implicitly) the conditional probabilities. If the evidence suggests something opposite of the prior, you lower your belief in the prior… and so on.
Pages 174 – 175: Also interesting here is the idea of leaning in / quasi-exposure therapy. Rather than avoiding the tough questions, facing them head on (for example, what would actually happen if this thing you’re afraid of happened?) can help resolve them.
Meanwhile, evaluating the consequences of certain patterns of thinking (and their alternatives) – and solving problems by coming up with different modes of thinking – can help.
Pages 181 – 182: Another interesting table of thinking errors. A useful table to review eery so often… covered here include schema, “catastrophizing,” and all-or-nothing (i.e. non- probabilistic) thinking.
Page 183: simple but effective: broadening your framing can be really helpful. I often find that if it looks like there are no solutions, I’m implicitly including some constraint that I didn’t think about and that I don’t need…
Page 185: again, a nice example of structural problem solving – anticipating problems and solving them before they come up.
Beck here also notes the idea of “devising an adaptive response.” I love the word adaptive…
Page 195: Here is an interesting modified journal format for evaluating thoughts. I think it can be helpful in avoiding hindsight bias, among other things.
Page 197: Beck cites an “AWARE” (accept, watch, act as if, repeat, expect the best) technique for dealing with anxiety.
Page 201: Again, evaluating how beliefs originated and became reinforced can be helpful in evaluating them – if you can re-contextualize the situation under which the maladaptive beliefs originated, you might be able to come to a new (and more adaptive) conclusion.
Page 206 – 207: on rephrasing, and also on asking why and looking for meanings. It’s very Howard Marks-esque second-level thinking: the “and then what.”
Pages 210 – 211: Really interesting bit here about pointing out that different people learn different sets of beliefs, and you too can learn different beliefs if you want to. ( Probabilistic thinking +scientific thinking.)
People usually don’t think of beliefs as learned… but they don’t just spring from nowhere. (Disaggregation.)
Page 212: We’re at the point where a lot of stuff starts to sound similar… Beck notes that the same processes used to evaluate automatic thoughts can be used to evaluate beliefs. Basically, evaluating the evidence for and against a belief, and the adaptivity or maladaptivity of maintaining that belief.
Page 213: Nice table here demonstrating how maladaptive beliefs can be replaced by moreadaptive (often more nuanced and probabilistic) beliefs. Again, the way to get here isn’t brute force, but rather incremental collaborative empiricism.
Page 214: Beck provides a number of demonstrated techniques to help modify automatic thoughts.
Page 215: There’s some nice reasoning/analogy here… for example, to help a patient who doesn’t want to ask to be help, Beck sets the patient up to answer the question of who is more competent/reasonable: someone who struggles unnecessarily, or someone who asks for help and uses it to improve.
I cite this specific example because there’s an unfortunate tendency, especially among males, to not ask for help and view needing help as a sign of weakness…
Page 217: a practical a/b test here, as well as some counterfactuals to a belief.
One way to reframe CBT in Tavris/Aronson terms is that you as the therapist are forcing the patient to experience cognitive dissonance by highlighting a conflict between the belief system / automatic thought and external reality… then, instead of allowing them to resolve that dissonance via confirmation bias, you basically don’t give them that option and guide them into the other path, i.e. reevaluating the belief to match reality.
Page 219: I think this number-line “cognitive continuum” is actually really helpful. You know how I said in the notes to Ellenberg’s How Not To Be Wrong ( HNW review + notes) that I figured there was a practical use for the sandwich theorem from calculus? Well, here it is.
Evaluating things in the absolute can be difficult – how good of a student am I? But, the way we’re wired, we can utilize contrast bias – pretty easy to see things that are clearly better/worse than us.
So, in this case, Beck highlights the example of her patient feeling like she’s a terrible, terrible student. The solution is to find other examples of students and put them on a number line in relation to the patient. The worst possible student is a 0, a real slacker is to the right of that, etc…
… the point isn’t to convince the patient that they’re a star student (they won’t believe it), but rather to debottleneck their schema and help them realize where they actually stand.
Page 220: Again, here, in therapist mode, Beck stresses the importance of probabilistic thinking – not evaluating the world in terms of binary all-or-nothings (good student / bad student), but rather in terms of degrees (better student / worse student).
Page 221: Also a good example here of reductio ad absurdum: following an errant thought pattern to its logical conclusion…
Page 223: Nice practical demonstration of “help a friend” here – separates us from our own “ inside view.”
Pages 226 – 227: Another techniques – one is a quasi “fake it ‘til you make it” – even if you can’t change your belief, act as if you’d changed the belief and see what happens. (i.e., exhibit the behaviors that you would exhibit if you had a different belief.) Sort of like trying on a new belief in a dressing room.
And a nice bit on the mental models approach (implicitly) – i.e. figuring out which beliefs you hold are both maladaptive and very not- useful, then using probabilistic thinking, a/b testing, and exploiting cognitive biases like contrast bias to replace those beliefs with better ones.
Page 228: Beck notes that it’s surprisingly common for people to not really be able to articulate their core beliefs until pressed.
Depressed people basically have the inverse of fundamental attribution error.
Page 234: the “downward arrow technique” is a kind of neat second-level thinking exercise. It basically involves asking “and then what” – or “what does that mean.”
Page 236: again, at this point most readers will get the point, but we’re applying the same theory to core beliefs as we did to automatic thoughts – that they’re ideas, not necessarily true; that we can test them, and change them…
Page 239: Beck notes that bibliotherapy (i.e. reading) can reinforce therapy, and recommends some books. If reading is therapy, then by god I’ve had a lot of therapy 😛
Pages 242 – 244: Some more techniques here… one of the interesting ones is a take on the Ben Franklin pros and cons approach: write down evidence supporting the old belief, and evidence supporting the old belief, and then reframe the old beliefs in a more realistic way…
think about thecounterfactuals.
Page 247: here’s an example of the earlier “continuum” contrast in action…
Pages 259 – 260: more ben franklin advantages/disadvantages. Also, occasionally, if automatic thoughts are too intrusive and unmanageable, just refocus attention elsewhere. (easier said than done)
Pages 264 – 266: Another nice example of disaggregation: it can often be easier to solve a problem by breaking it down into attainable steps. (Again, see Tetlock.)
Also, Beck here cites the idea of “exposure” – again, it’s a behavioral a/b test. If you think you’ll hate something, write down how you think you’ll feel after doing it, then do it, then compare how you actually feel with your prediction.
Here’s a practical example from my life: I often get frustrated at how long it takes me to do something (say, finish a research document on a stock, or read a book and take notes on it, or so on.)
Reframing helps a lot with that: one way to think about how long it takes me to read a book is “ugh, I spent [X hours] reading this book and now I’m [Y hours] into taking notes and I’m still not done, and I feel like I should’ve been done with this [Z hours ago.]”
As Beck would put it, perhaps there’s a grain of truth in that idea, and I could’ve been less distracted / etc. But beating myself up over it won’t make me go any faster.
On the other hand, it’s more motivating to realize – hey, this is a book that could be taught as a semester-long college course which I’d spend 3 hours a week in for 12 – 16 weeks, plus I’d have homework and studying on top of that… so even if getting through this book takes what seems like a long time, it’s a huge “bargain” relative to taking a college course on the same topic!
Page 275: the idea of a “credit list” seems like a nice way to reinforce desired behaviors.
Page 317: the “Texas/Florida” graph is perhaps a more accessible version of the X + sin(x) graph that I use in my head to visualize progress. It’s not always straightforward… it definitely helps to know that it’s going to be lumpy.
Pages 318 – 319: more on feedback and reinforcement. ALso a nice table at the bottom of 319.
Page 332: A nice coda from Beck: she notes that at all times, you should be asking “What is the specific problem here, and what am I trying to accomplish?”
First Read: spring 2018
Last Read: spring 2018
Number of Times Read: 1
Planning to Read Again?: ABSOLUTELY
Review Date: spring 2018
Notes Date: spring 2018