Cognitive distortion

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A cognitive distortion is a thought that causes a person to perceive reality inaccurately due to being exaggerated or irrational. Cognitive distortions are involved in the onset or perpetuation of psychopathological states, such as depression and anxiety. [1]

Contents

According to Aaron Beck's cognitive model, a negative outlook on reality, sometimes called negative schemas (or schemata), is a factor in symptoms of emotional dysfunction and poorer subjective well-being. Specifically, negative thinking patterns reinforce negative emotions and thoughts. [2] During difficult circumstances, these distorted thoughts can contribute to an overall negative outlook on the world and a depressive or anxious mental state. According to hopelessness theory and Beck's theory, the meaning or interpretation that people give to their experience importantly influences whether they will become depressed and whether they will experience severe, repeated, or long-duration episodes of depression. [3]

Challenging and changing cognitive distortions is a key element of cognitive behavioral therapy (CBT).

Definition

Cognitive comes from the Medieval Latin cognitīvus, equivalent to Latin cognit(us), 'known'. [4] Distortion means the act of twisting or altering something out of its true, natural, or original state. [5]

History

In 1957, American psychologist Albert Ellis, though he did not know it yet, would aid cognitive therapy in correcting cognitive distortions and indirectly helping David D. Burns in writing The Feeling Good Handbook . Ellis created what he called the ABC Technique of rational beliefs. The ABC stands for the activating event, beliefs that are irrational, and the consequences that come from the beliefs. Ellis wanted to prove that the activating event is not what caused the emotional behavior or the consequences, but the beliefs and how the person irrationally perceives the events which aid the consequences. [6] With this model, Ellis attempted to use rational emotive behavior therapy (REBT) with his patients, in order to help them "reframe" or reinterpret the experience in a more rational manner. In this model, Ellis explains it all to his clients, while Beck helps his clients figure this out on their own. [7] Beck first started to notice these automatic distorted thought processes when practicing psychoanalysis, while his patients followed the rule of saying anything that comes to mind. He realized that his patients had irrational fears, thoughts, and perceptions that were automatic. Beck began noticing his automatic thought processes that he knew his patients had but did not report. Most of the time the thoughts were biased against themselves and very erroneous. [8]

Beck believed that the negative schemas developed and manifested themselves in the perspective and behavior. The distorted thought processes led to focusing on degrading the self, amplifying minor external setbacks, experiencing other's harmless comments as ill-intended, while simultaneously seeing self as inferior. Inevitably cognitions are reflected in their behavior with a reduced desire to care for oneself, reduced desire to seek pleasure, and finally give up. These exaggerated perceptions, due to cognition, feel real and accurate because the schemas, after being reinforced through the behavior, tend to become 'knee-jerk' automatic and do not allow time for reflection. [9] This cycle is also known as Beck's cognitive triad, focused on the theory that the person's negative schema applied to the self, the future, and the environment. [10]

In 1972, psychiatrist, psychoanalyst, and cognitive therapy scholar Aaron T. Beck published Depression: Causes and Treatment. [11] He was dissatisfied with the conventional Freudian treatment of depression because there was no empirical evidence for the success of Freudian psychoanalysis. Beck's book provided a comprehensive and empirically supported theoretical model for depression—its potential causes, symptoms, and treatments. In Chapter 2, titled "Symptomatology of Depression", he described "cognitive manifestations" of depression, including low self-evaluation, negative expectations, self-blame and self-criticism, indecisiveness, and distortion of the body image. [11]

Beck's student David D. Burns continued research on the topic. In his book Feeling Good: The New Mood Therapy , Burns described personal and professional anecdotes related to cognitive distortions and their elimination. [12] When Burns published Feeling Good: The New Mood Therapy, it made Beck's approach to distorted thinking widely known and popularized. [13] [14] Burns sold over four million copies of the book in the United States alone. It was a book commonly "prescribed" for patients with cognitive distortions that have led to depression. Beck approved of the book, saying that it would help others alter their depressed moods by simplifying the extensive study and research that had taken place since shortly after Beck had started as a student and practitioner of psychoanalytic psychiatry. Nine years later, The Feeling Good Handbook was published, which was also built on Beck's work and includes a list of ten specific cognitive distortions that will be discussed throughout this article. [15]

Main types

Examples of some common cognitive distortions seen in depressed and anxious individuals. People may be taught how to identify and alter these distortions as part of cognitive behavioural therapy. Common Cognitive Biases.png
Examples of some common cognitive distortions seen in depressed and anxious individuals. People may be taught how to identify and alter these distortions as part of cognitive behavioural therapy.

John C. Gibbs and Granville Bud Potter propose four categories for cognitive distortions: self-centered, blaming others, minimizing-mislabeling, and assuming the worst. [16] The cognitive distortions listed below are categories of negative self-talk. [15] [17] [18] [19]

All-or-nothing thinking

The "all-or-nothing thinking distortion" is also referred to as "splitting", [20] "black-and-white thinking", [2] and "polarized thinking." [21] Someone with the all-or-nothing thinking distortion looks at life in black and white categories. [15] Either they are a success or a failure; either they are good or bad; there is no in-between. According to one article, "Because there is always someone who is willing to criticize, this tends to collapse into a tendency for polarized people to view themselves as a total failure. Polarized thinkers have difficulty with the notion of being 'good enough' or a partial success." [20]

This example captures the polarized nature of this distortion—the person believes they are totally inadequate if they fall short of perfection. In order to combat this distortion, Burns suggests thinking of the world in terms of shades of gray. [15] Rather than viewing herself as a complete failure for eating a spoonful of ice cream, the woman in the example could still recognize her overall effort to diet as at least a partial success.

This distortion is commonly found in perfectionists. [13]

Jumping to conclusions

Reaching preliminary conclusions (usually negative) with little (if any) evidence. Three specific subtypes are identified:[ citation needed ]

Mind reading

Inferring a person's possible or probable (usually negative) thoughts from their behaviour and nonverbal communication; taking precautions against the worst suspected case without asking the person.

  • Example 1: A student assumes that the readers of their paper have already made up their minds concerning its topic, and, therefore, writing the paper is a pointless exercise. [19]
  • Example 2: Kevin assumes that because he sits alone at lunch, everyone else must think he is a loser. (This can encourage self-fulfilling prophecy; Kevin may not initiate social contact because of his fear that those around him already perceive him negatively). [22]

Fortune-telling

Predicting outcomes (usually negative) of events.

  • Example: A depressed person tells themselves they will never improve; they will continue to be depressed for their whole life. [15]

One way to combat this distortion is to ask, "If this is true, does it say more about me or them?" [23]

Labelling

Labelling occurs when someone overgeneralizes the characteristics of other people. Someone might use an unfavourable term to describe a complex person or event, such as assuming that a friend is upset with them due to a late reply to a text message, even though there could be various other reasons for the delay. It is a more extreme form of jumping-to-conclusions cognitive distortion where one presumes to know the thoughts, feelings, or intentions of others without any factual basis.

Emotional reasoning

In the emotional reasoning distortion, it is assumed that feelings expose the true nature of things and experience reality as a reflection of emotionally linked thoughts; something is believed true solely based on a feeling.

Should/shouldn't and must/mustn't statements

Making "must" or "should" statements was included by Albert Ellis in his rational emotive behavior therapy (REBT), an early form of CBT; he termed it "musturbation". Michael C. Graham called it "expecting the world to be different than it is". [25] It can be seen as demanding particular achievements or behaviors regardless of the realistic circumstances of the situation.

A related cognitive distortion, also present in Ellis' REBT, is a tendency to "awfulize"; to say a future scenario will be awful, rather than to realistically appraise the various negative and positive characteristics of that scenario. According to Burns, "must" and "should" statements are negative because they cause the person to feel guilty and upset at themselves. Some people also direct this distortion at other people, which can cause feelings of anger and frustration when that other person does not do what they should have done. He also mentions how this type of thinking can lead to rebellious thoughts. In other words, trying to whip oneself into doing something with "shoulds" may cause one to desire just the opposite. [15]

Gratitude traps

A gratitude trap is a type of cognitive distortion that typically arises from misunderstandings regarding the nature or practice of gratitude.[ citation needed ] The term can refer to one of two related but distinct thought patterns:

Personalization and blaming

Personalization is assigning personal blame disproportionate to the level of control a person realistically has in a given situation.

Blaming is the opposite of personalization. In the blaming distortion, the disproportionate level of blame is placed upon other people, rather than oneself. [15] In this way, the person avoids taking personal responsibility, making way for a "victim mentality".

Always being right

In this cognitive distortion, being wrong is unthinkable. This distortion is characterized by actively trying to prove one's actions or thoughts to be correct, and sometimes prioritizing self-interest over the feelings of another person. [2] [ unreliable source? ] In this cognitive distortion, the facts that oneself has about their surroundings are always right while other people's opinions and perspectives are wrongly seen. [27] [ unreliable source? ]

Fallacy of change

Relying on social control to obtain cooperative actions from another person. [2] The underlying assumption of this thinking style is that one's happiness depends on the actions of others. The fallacy of change also assumes that other people should change to suit one's own interests automatically, and/or that it is fair to pressure them to change. It may be present in most abusive relationships in which partners' "visions" of each other are tied into the belief that happiness, love, trust, and perfection would just occur once they or the other person change aspects of their beings. [28]

Minimizing-mislabeling

Magnification and minimization

Giving proportionally greater weight to a perceived failure, weakness or threat, or lesser weight to a perceived success, strength or opportunity, so that the weight differs from that assigned by others, such as "making a mountain out of a molehill". In depressed clients, often the positive characteristics of other people are exaggerated, and their negative characteristics are understated.

Catastrophizing is a form of magnification where one gives greater weight to the worst possible outcome, however unlikely, or experiences a situation as unbearable or impossible when it is just uncomfortable.

Labeling and mislabeling

A form of overgeneralization; attributing a person's actions to their character instead of to an attribute. Rather than assuming the behaviour to be accidental or otherwise extrinsic, one assigns a label to someone or something that is based on the inferred character of that person or thing.

Assuming the worst

Overgeneralizing

Someone who overgeneralizes makes faulty generalizations from insufficient evidence. Such as seeing a "single negative event" as a "never-ending pattern of defeat", [15] and as such drawing a very broad conclusion from a single incident or a single piece of evidence. Even if something bad happens only once, it is expected to happen over and over again. [2]

  • Example 1: A person is asked out on a first date, but not a second one. They are distraught as tells a friend, "This always happens to me! I'll never find love!"
  • Example 2: A person is lonely and often spends most of their time at home. Friends sometimes ask them to dinner and to meet new people. They feel it is useless to even try. No one could really like them. And anyway, all people are the same: petty and selfish. [24]

One suggestion to combat this distortion is to "examine the evidence" by performing an accurate analysis of one's situation. This aids in avoiding exaggerating one's circumstances. [15]

Disqualifying the positive

Disqualifying the positive refers to rejecting positive experiences by insisting they "don't count" for some reason or other. Negative belief is maintained despite contradiction by everyday experiences. Disqualifying the positive may be the most common fallacy in the cognitive distortion range; it is often analyzed with "always being right", a type of distortion where a person is in an all-or-nothing self-judgment. People in this situation show signs of depression. Examples include:

  • "I will never be as good as Jane"
  • "Anyone could have done as well" [15]
  • "They are just congratulating me to be nice" [29]

Mental filtering

Filtering distortions occur when an individual dwells only on the negative details of a situation and filters out the positive aspects. [15]

  • Example: Andy gets mostly compliments and positive feedback about a presentation he has done at work, but he also has received a small piece of criticism. For several days following his presentation, Andy dwells on this one negative reaction, forgetting all of the positive reactions that he had also been given. [15]

The Feeling Good Handbook notes that filtering is like a "drop of ink that discolors a beaker of water". [15] One suggestion to combat filtering is a cost–benefit analysis. A person with this distortion may find it helpful to sit down and assess whether filtering out the positive and focusing on the negative is helping or hurting them in the long run. [15]

Conceptualization

In a series of publications, [30] [31] [32] philosopher Paul Franceschi has proposed a unified conceptual framework for cognitive distortions designed to clarify their relationships and define new ones. This conceptual framework is based on three notions: (i) the reference class (a set of phenomena or objects, e.g. events in the patient's life); (ii) dualities (positive/negative, qualitative/quantitative, ...); (iii) the taxon system (degrees allowing to attribute properties according to a given duality to the elements of a reference class). In this model, "dichotomous reasoning", "minimization", "maximization" and "arbitrary focus" constitute general cognitive distortions (applying to any duality), whereas "disqualification of the positive" and "catastrophism" are specific cognitive distortions, applying to the positive/negative duality. This conceptual framework posits two additional cognitive distortion classifications: the "omission of the neutral" and the "requalification in the other pole".

Cognitive restructuring

Cognitive restructuring (CR) is a popular form of therapy used to identify and reject maladaptive cognitive distortions, [33] and is typically used with individuals diagnosed with depression. [34] In CR, the therapist and client first examine a stressful event or situation reported by the client. For example, a depressed male college student who experiences difficulty in dating might believe that his "worthlessness" causes women to reject him. Together, therapist and client might then create a more realistic cognition, e.g., "It is within my control to ask girls on dates. However, even though there are some things I can do to influence their decisions, whether or not they say yes is largely out of my control. Thus, I am not responsible if they decline my invitation." CR therapies are designed to eliminate "automatic thoughts" that include clients' dysfunctional or negative views. According to Beck, doing so reduces feelings of worthlessness, anxiety, and anhedonia that are symptomatic of several forms of mental illness. [35] CR is the main component of Beck's and Burns's CBT. [36]

Narcissistic defense

Those diagnosed with narcissistic personality disorder tend, unrealistically, to view themselves as superior, overemphasizing their strengths and understating their weaknesses. [35] Narcissists use exaggeration and minimization this way to shield themselves against psychological pain. [37] [38]

Decatastrophizing

In cognitive therapy, decatastrophizing or decatastrophization is a cognitive restructuring technique that may be used to treat cognitive distortions, such as magnification and catastrophizing, [39] commonly seen in psychological disorders like anxiety [34] and psychosis. [40] Major features of these disorders are the subjective report of being overwhelmed by life circumstances and the incapability of affecting them.

Criticism

Common criticisms of the diagnosis of cognitive distortion relate to epistemology and the theoretical basis. If the perceptions of the patient differ from those of the therapist, it may not be because of intellectual malfunctions, but because the patient has different experiences. In some cases, depressed subjects appear to be "sadder but wiser". [41]

See also

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Type of therapy to improve mental health

Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD and anxiety disorders. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

<span class="mw-page-title-main">Aaron Beck</span> American psychiatrist and academic (1921–2021)

Aaron Temkin Beck was an American psychiatrist who was a professor in the department of psychiatry at the University of Pennsylvania. He is regarded as the father of cognitive therapy and cognitive behavioral therapy (CBT). His pioneering methods are widely used in the treatment of clinical depression and various anxiety disorders. Beck also developed self-report measures for depression and anxiety, notably the Beck Depression Inventory (BDI), which became one of the most widely used instruments for measuring the severity of depression. In 1994 he and his daughter, psychologist Judith S. Beck, founded the nonprofit Beck Institute for Cognitive Behavior Therapy, which provides CBT treatment and training, as well as research. Beck served as President Emeritus of the organization up until his death.

Rational emotive behavior therapy (REBT), previously called rational therapy and rational emotive therapy, is an active-directive, philosophically and empirically based psychotherapy, the aim of which is to resolve emotional and behavioral problems and disturbances and to help people to lead happier and more fulfilling lives.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Depressive realism is the hypothesis developed by Lauren Alloy and Lyn Yvonne Abramson that depressed individuals make more realistic inferences than non-depressed individuals. Although depressed individuals are thought to have a negative cognitive bias that results in recurrent, negative automatic thoughts, maladaptive behaviors, and dysfunctional world beliefs, depressive realism argues not only that this negativity may reflect a more accurate appraisal of the world but also that non-depressed individuals' appraisals are positively biased.

Emotional reasoning is a cognitive process by which an individual concludes that their emotional reaction proves something is true, despite contrary empirical evidence. Emotional reasoning creates an 'emotional truth', which may be in direct conflict with the inverse 'perceptional truth'. It can create feelings of anxiety, fear, and apprehension in existing stressful situations, and as such, is often associated with or triggered by panic disorder or anxiety disorder. For example, even though a spouse has shown only devotion, a person using emotional reasoning might conclude, "I know my spouse is being unfaithful because I feel jealous."

<span class="mw-page-title-main">Beck's cognitive triad</span> Three key elements of depression

Beck's cognitive triad, also known as the negative triad, is a cognitive-therapeutic view of the three key elements of a person's belief system present in depression. It was proposed by Aaron Beck in 1967. The triad forms part of his cognitive theory of depression and the concept is used as part of CBT, particularly in Beck's "Treatment of Negative Automatic Thoughts" (TNAT) approach.

Self-criticism involves how an individual evaluates oneself. Self-criticism in psychology is typically studied and discussed as a negative personality trait in which a person has a disrupted self-identity. The opposite of self-criticism would be someone who has a coherent, comprehensive, and generally positive self-identity. Self-criticism is often associated with major depressive disorder. Some theorists define self-criticism as a mark of a certain type of depression, and in general people with depression tend to be more self critical than those without depression. People with depression are typically higher on self-criticism than people without depression, and even after depressive episodes they will continue to display self-critical personalities. Much of the scientific focus on self-criticism is because of its association with depression.

Learned optimism is the idea in positive psychology that a talent for joy, like any other, can be cultivated. In contrast with learned helplessness, optimism is learned by consciously challenging any negative self talk.

<span class="mw-page-title-main">David D. Burns</span> American professor of psychiatry

David D. Burns is an American psychiatrist and adjunct professor emeritus in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. He is the author of bestselling books such as Feeling Good: The New Mood Therapy, The Feeling Good Handbook and Feeling Great: The Revolutionary New Treatment for Depression and Anxiety.

Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses. This involves the individual working with the therapist to develop skills for testing and changing beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. A cognitive case conceptualization is developed by the cognitive therapist as a guide to understand the individual's internal reality, select appropriate interventions and identify areas of distress.

Splitting, also called binary thinking, black-and-white thinking, all-or-nothing thinking, or thinking in extremes, is the failure in a person's thinking to bring together the dichotomy of both perceived positive and negative qualities of something into a cohesive, realistic whole. It is a common defense mechanism, wherein the individual tends to think in extremes. This kind of dichotomous interpretation is contrasted by an acknowledgement of certain nuances known as "shades of gray".

Behavioral theories of depression explain the etiology of depression based on the behavioural sciences, and they form the basis for behavioral therapies for depression.

Arbitrary inference is a classic tenet of cognitive therapy created by Aaron T. Beck in 1979. He defines the act of making an arbitrary inference as the process of drawing a conclusion without sufficient evidence, or without any evidence at all. In cases of depression, Beck found that individuals may be more prone to cognitive distortions, and make arbitrary inferences more often. These inferences could be general and/or in reference to the effectiveness of their medicine or treatment. Arbitrary inference is one of numerous specific cognitive distortions identified by Beck that can be commonly presented in people with anxiety, depression, and psychological impairments.

<span class="mw-page-title-main">Rumination (psychology)</span> Focused attention

Rumination is the focused attention on the symptoms of one's mental distress. In 1998, Nolen-Hoeksema proposed the Response Styles Theory, which is the most widely used conceptualization model of rumination. However, other theories have proposed different definitions for rumination. For example, in the Goal Progress Theory, rumination is conceptualized not as a reaction to a mood state, but as a "response to failure to progress satisfactorily towards a goal". According to multiple studies, rumination is a mechanism that develops and sustains psychopathology conditions such as anxiety, depression, and other negative mental disorders. There are some defined models of rumination, mostly interpreted by the measurement tools. Multiple tools exist to measure ruminative thoughts. Treatments specifically addressing ruminative thought patterns are still in the early stages of development.

<i>Feeling Good: The New Mood Therapy</i> Book by David D. Burns

Feeling Good: The New Mood Therapy is a book written by David D. Burns, first published in 1980, that popularized cognitive behavioral therapy (CBT).

Cognitive reframing is a psychological technique that consists of identifying and then changing the way situations, experiences, events, ideas and emotions are viewed. Cognitive reframing is the process by which such situations or thoughts are challenged and then changed. In the context of cognitive therapy, cognitive reframing is referred to as cognitive restructuring.

Logic-based therapy (LBT) is a modality of philosophical counseling developed by philosopher Elliot D. Cohen beginning in the mid-1980s. It is a philosophical variant of rational emotive behavior therapy (REBT), which was developed by psychologist Albert Ellis. A randomized, controlled efficacy study of LBT suggests that it may be effective in reducing anxiety.

Self-blame is a cognitive process in which an individual attributes the occurrence of a stressful event to oneself. The direction of blame often has implications for individuals’ emotions and behaviors during and following stressful situations. Self-blame is a common reaction to stressful events and has certain effects on how individuals adapt. Types of self-blame are hypothesized to contribute to depression, and self-blame is a component of self-directed emotions like guilt and self-disgust. Because of self-blame's commonality in response to stress and its role in emotion, self-blame should be examined using psychology's perspectives on stress and coping. This article will attempt to give an overview of the contemporary study on self-blame in psychology.

The gratitude trap is a type of cognitive distortion that typically arises from misunderstandings regarding the nature or practice of gratitude. It is closely related to fallacies such as emotional reasoning and the "fallacy of change" identified by psychologists and psychotherapists such as John M. Grohol, Peter Ledden, and others.

References

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  35. 1 2 Diagnostic and statistical manual of mental disorders : DSM-5 . American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force. (5th ed.). Arlington, VA: American Psychiatric Association. 2013. ISBN   9780890425541. OCLC   830807378.{{cite book}}: CS1 maint: others (link)
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  37. ↑ Millon, Theodore; Carrie M. Millon; Seth Grossman; Sarah Meagher; Rowena Ramnath (2004). Personality Disorders in Modern Life. John Wiley and Sons. ISBN   978-0-471-23734-1.
  38. ↑ Thomas, David (2010). Narcissism: Behind the Mask. Book Guild. ISBN   978-1-84624-506-0.
  39. ↑ Theunissen, Maurice; Peters, Madelon L.; Bruce, Julie; Gramke, Hans-Fritz; Marcus, Marco A. (2012). "Preoperative Anxiety and Catastrophizing" (PDF). The Clinical Journal of Pain. 28 (9): 819–841. doi:10.1097/ajp.0b013e31824549d6. PMID   22760489. S2CID   12414206.
  40. ↑ Moritz, Steffen; Schilling, Lisa; Wingenfeld, Katja; Köther, Ulf; Wittekind, Charlotte; Terfehr, Kirsten; Spitzer, Carsten (2011). "Persecutory delusions and catastrophic worry in psychosis: Developing the understanding of delusion distress and persistence". Journal of Behavior Therapy and Experimental Psychiatry. 42 (September 2011): 349–354. doi:10.1016/j.jbtep.2011.02.003. PMID   21411041.
  41. ↑ Beidel, Deborah C. (1986). "A Critique of the Theoretical Bases of Cognitive Behavioral Theories and Therapy". Clinical Psychology Review. 6 (2): 177–97. doi:10.1016/0272-7358(86)90011-5.
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