CHILD & FAMILY BEHAVIOR THERAPY
2016, VOL. 38, NO. 1, 69–103
BOOK REVIEWS
Evans, I. M. (2015). Why Thoughts Change: Foundations of Cognitive
Psychotherapy. New York, NY: Oxford University Press, xiii þ 255 pp.,
$59.95 (hardcover).
Evans, when living in the United States, was Director of Clinical Training at
the State University of New York at Binghamton. Currently he is Professor of
Psychology at Massey University in New Zealand, where he also served as
president of the New Zealand Psychological Society. Evans’ research has
focused on positive approaches to challenging behavior in children, especially
those with severe disabilities. He has studied the emotional development of
children at home, at school; and studied the theory, practice, and ethics of
what he terms culturally informed cognitive behavior therapy. In 2014 I
had the pleasure of reviewing his previous book How and Why People Change.
In my summary of that book I noted that his How and Why book was a very
thought-provoking, detailed, and well thought out book. It challenged some of
the basic tenets behind the provision of psychotherapy and helped us think
about what therapy is really about. It was not easy reading but was highly stimulating
if one took time and really considered the various questions and
points that Evans introduced and addressed. I believed that that book would
be a valuable contribution to any course on the psychotherapy process or
course on the theory of therapy. This next book continues in that tradition
and is equally thought-provoking, detailed, and well thought out. The book
begins with a highly informative preface, followed by nine chapters beginning
with an introduction, followed by a review of basic concepts of cognitive
therapies, leading to a discussion of “thinking about thoughts.” Evans then
addresses mind wandering, introspection, rumination, meditation, and mindfulness
followed by an examination of distorted thoughts, how thoughts influence
moods and feelings, how thoughts lead to action, general principles of
how and why thoughts change, and a final chapter which examines how cognitive
treatments can be improved or enhanced.
Evans notes that cognitive behavior therapy is a treatment system designed
to help individuals overcome life challenges by identifying and altering maladaptive
thinking. Within it, clients are encouraged to develop skills for
rehearsing new, more functional mental habits, to test assumptions underlying
misattributions, and to question erroneous beliefs and the attitudes that
those beliefs create. Individuals are trained to identify and reconsider distorted
judgments and, while negative feelings cannot and should not be
avoided, restructuring memories of past negative emotional experience can
be beneficial. Cognitive therapy addresses conscious thoughts as well as those
unconscious processes involved in thinking—of which we are often not aware.
Evans makes the point that cognitive therapy does not try to alter every
erroneous inference, only those that create distress, dysfunction, or avoidable
unhappiness. Many subtleties are examined such as whether a happy thought
is truly a thought or just a verbal report of a feeling. Evans questions whether
thoughts cause emotions or whether there is a bidirectionality between
thoughts and emotions. He questions whether we can really find the cause
of a thought and whether thoughts alone cause overt behaviors. While there
are many “brands” of cognitive therapy, Evan tries to find unifying factors. He
additionally believes it is unwise to separate cognitive therapies from traditional
behavior therapy. Cognitive therapies emerged because, at times
when working with adults and adolescents, the only tools available are linguistic.
Evans—along with Hayes, Pistorello, and Levin (2012), Kazdin (2001), and
Staats (1983)—believe that it is both appropriate and important to create a
unified model of change in order to enhance treatment research progress.
As such, Evans notes that the purpose of his book “is to re-examine the
assumptions underlying cognitive therapy by explaining contemporary developments
within a general cognitive psychology.”
Evans notes that the study of psychology is typically framed as the science of
behavior and that behavior has expanded to now include everything we do
including cognition and affect. He correctly points out that this was not always
the case. In the late 19th century when psychology emerged as a science, it
focused on consciousness and the way in which people knew and perceived
the world around them. Over the years, it has become accepted that people
are often not consciously aware and that internal processes often have a potent
impact on behavior thus leading to a cognitive shift that included more than
consciousness. Consciousness gave way to a functionalism and the science of
behavior with focus on what people did rather than what they were thinking
or aware of. This behavioral shift gave rise to many effective methods of intervention
and, as more and more people came to behavior therapists, the fact that
something was missing became eminently clear. This reality became the fertile
ground from which cognitive psychotherapy and cognitive psychology
emerged. Many have argued that it is important to not split cognitive therapy
from its behavioral roots and the term cognitive behavior therapy (CBT) was
created, meant to create a unifying bridge between these two interventional
styles. Evans notes that most texts on cognitive interventions assume that most
nonchild clients are reasonably verbal, have a basic education, are open to
psychological interpretations, are willing to trust, and are able to explain their
concerns and thoughts. Those that have proficiency in all of these skills tend to
benefit most from cognitive interventions.
Some thoughts tend to be free-floating and are easier to manipulate. They
can be extended, expanded, and associated with other thoughts in creative in
novel ways. Opinions, beliefs, intentions, and attitudes tend to be more fixed
and more challenging to alter yet, these are the constructs most focused upon
in CBT. Knowledge, which comprises ideas, thoughts, beliefs, and attitudes
can be overt and can also be implicit. Thoughts can be about the causes of
behavior and are frequently termed attributions. Attributions can focus on
the self and internal processes or can focus on external process. Attributions
can be stable or unstable and can focus on a singular event or be more global.
Evans notes that individuals with clinical problems such as anxiety and
depression tend to have attributions that are internal—i.e., where the self is
blamed, stable, and global. Collections of thoughts that are consistent and
have related attitudes and beliefs are often seen within the context of a
schema. Schemas provide an organized pattern of thought and provide a
framework for interpreting and understanding new events and interpersonal
encounters. Schemas combine emotional content of past experience with a
language interpretive construct.
Thoughts, unless verbalized, tend to be personal and private. For some,
thoughts can be easily self-regulated and for others far less so. Individuals
in therapy will often report only the content of key or dominant thoughts
and, unless probed by the clinician’s questioning, often leave out many details
of therapeutic interest. For many, the process of expressing a thought is not
connected with an awareness of how that thought was generated!
As noted, many different forms of cognitive therapy have emerged, the
most prominent ones being attached to the name of the particular individual
who originated and popularized the method such as Ellis with rational emotive
behavior therapy (REBT), Beck and cognitive therapy, Young and schema
focused therapy, Lynehan and dialectical behavior therapy (DBT), and Hayes
with acceptance and commitment therapy (ACT). All systems do believe that
change occurs through altering thoughts, thought patterns, and thought functions.
Most do it directly while ACT believes it must be done indirectly. In his
chapter on Changing Thoughts in Practice, Evans reviews all of these cognitive
strategies and compares their similarities and differences. One difference
noted is that many of these different systems emerged as a focused treatment
for a specific diagnostic category or psychiatric syndrome. While there are
identifiable, universal core processes that can be identified in most of them,
they all emerged with separate focuses.
In Evans’ Thinking About Thoughts he notes that thought is nonmaterial
and that developing a definition of thought and thought processes that is consistent
with current psychological knowledge is a genuine challenge. He
humorously notes the relief that early psychologists must have felt when they
defined observable behavior as the focus of early behavioral science, as behaviors
were much more definable than early attempts to deal with consciousness
which led to such conundrums as “how many angels can dance on the
head of a pin!”.
Cognitive therapy has tended to focus on words and treats thought content
as words even if subvocalized. At times, single words can serve as a cue and at
other times a string of words may be needed to serve as a message about
reality or what to expect. If this word string rests on faulty reasoning, expectations,
or attributions, feelings will be based on error and can queue negative
emotions. Cognitive therapy, by focusing on words, moves away from
instinct, “gut feeling,” or intuition; instead, focusing on verbal inner experience
as the presumed cause of distress. One question discussed by Evans
reflects whether a thought is a representation of a mental event or, is it the
mental event itself? His answer is fascinating reading and leads to the conclusion
that there is often a nonverbal level in which a coherent system of
expectations, assumptions, and emotional connections exist that guides behavior
even in the absence of a conscious verbally complex thought. Evans then
examines cognitive distortions, noting that all cognitive therapies revolve
around strategies to alter such distortions. He examines where such distorted
thoughts and processing styles come from. Most attribute such distortions to
early childhood learning which tend to be perpetuated through generations.
He explains that this is a somewhat simplistic notion that we all carry and
really does not serve to answer the question. Once again, Evans’ discussion
of this issue is intriguing as is his discussion of “where do thoughts go when
we are not thinking them?” To answer this, Evans reviews the storage of such
thoughts in memory and contrasts episodic memory (the storage of particular
experience) with semantic memory where ideas, thoughts, and dreams are
stored. Traumatic experiences are often laid down in vivid detail in both
memories and are often experienced when not wanted. Memory is often
adaptive and people differentially attend to and remember threatening
information which, for those more vulnerable, can lead to emotional distress.
Schemas are often seen as a memory phenomenon as they entail the storage of
a thought along with imaginal, verbal, affective, and contextual information.
Evans’ discussion of the various aspects of memory is both interesting and
important reading.
Evans makes a distinction between thoughts versus thinking. Thoughts
become the accessible and retrievable content of one’s conscious experience.
Thinking is the manipulation of symbols which for many is primarily done
with language in order to generate new ideas or novel approaches to circumstances.
One aspect of cognitive therapy is assisting individuals to derive
conclusions based on reality and practicality rather than prejudicial, distorted,
or wishful thinking. For some, this can be especially challenging such that
individuals with depression often have difficulty with decision-making, tend
to vacillate between ideas and deal with the unpleasantness of decisionmaking
by not making decisions. They tend to be aware of their nondecision-
making stance and this often generates more worry about how to
make up their minds which further leads to avoidance. Evans examines the
psychology of decision-making, reasoning, and creativity. Many therapies
teach problem-solving with much content emerging from laboratory studies
of decision-making by both novices and experts. There is often an assumption
that good decision-making follows a reasonable and linear sequence and
follows the plan of generating alternatives, generating pro and con criteria,
assessment of alternatives, selection of the seemingly most beneficial solution,
and then activating the choice. Individuals in therapy often have difficulty
with many of these steps. Frequently people “just go for it” making a spontaneous
choice, don’t make decisions at all, become dependent and look for
external direction and try to rely on intuition and gut feelings. Ease and
convenience are additional variables which take people away from fact-based
decision-making. All of these interfere with rational choice.
Mental activity is often illogical and unrestricted, leading people to have
minds that wander and ruminate. People spend a great deal of time in some
kind of mental activity, much of which is not ordered but consists of bits of
inner experiences, daydreams, rehashing of hoped-for or failed dialogues,
vivid imagery, and day dreaming. Few cognitive therapies have clearly
examined how particular thoughts, concerns, specific thought processes,
and coherent thematic clusters of ideas and feelings can be separated from
the daily noise of conscious experience. Evans then goes on to examine mind
wandering, rumination, worry, brooding, and daydreaming and introduces
the techniques of thought sampling to increase understanding of the cognitive
noise many people deal with. He introduces the concept of “flow” which is the
state of mind that people seek to achieve when they are “zoned in” on a particular
task or activity. Meditation and mindfulness are discussed at antidotes
that individuals with cluttered or disorganized minds can utilize to try to
decrease chaos and distress and to come to understand that thoughts are just
thoughts and, in the words of Hayes, to diffuse them from the potency of their
own internal thoughts and constructs.
Evans discriminates irrational thoughts, the “meat and potatoes” of cognitive
therapy, with distorted thoughts which include delusions, hallucinations,
and other processes typically linked to psychosis, dissociation, or obsessional
thinking. Hallucinations tend to be visual, auditory, olfactory, and sometimes
tactile. Delusions are more clearly thought based and are often similar to overvalued
ideas or other firmly held beliefs that are seen as false by the vast
majority of people. Delusions are often themed around personal threat or persecution,
impending disaster, or the wrongdoings of particular famous people.
Delusional thinking is seen as not only involving a breakdown in logical
reasoning and a relative lack of doubt and circumspection but is linked to
deep-seated fears and insecurities. Evans notes that delusions would best be
seen as functional in some way and serving particular needs. Trust must be
established in order to have therapists not be seen as a part of the problem
rather than potential agent of solution. Evans notes that challenging core
beliefs of individuals with schizophrenia is best done not through interrogation
but through an approach of curiosity. Evans’ chapter on distorted
thoughts is wide-ranging and offers a great deal of interesting, challenging,
and potentially useful information for clinicians.
In his discussion of how thoughts influence mood and feelings, Evans more
carefully defines these various terms, noting that moods tend to last for days
and even weeks. Emotion is seen as a general term for subjectively experienced
affective states. Feelings refer more directly to the subjective experiential
part of emotion and are cognitively mediated in that, it requires words for
their recognition and communication. Affect is overlapped with emotion but
tends to be related to a positive or negative attribution. Feelings are seldom
reported, in that there is often an affective assessment that conveys whether
the emotions felt come from a positive or negative triggering events for emotions
can be external or internal and even if external, there is typically a cognitive
mediator that influences feeling. There is an ongoing interaction
between personality and environment and individuals bring certain vulnerabilities
or predispositions into their interpretations of environmental events
which can easily lead to amplification or distortion and the generation of
negative feelings. Interestingly, the outcome of treatment studies do not confirm
or disconfirm the theory used in the development of different therapeutic
styles, only confirming that a particular treatment processes does make a
difference.
While “words are just words,” they are often felt as hurtful. Contextually,
when people explain such hurtful encounters they typically involve betrayal,
criticism, rejection, and critical messages from valued others. Evans notes that
the most widely accepted theory of emotion today is a cognitive appraisal
theory, noting that the impact of an event is a function of the assessment
of the meaning behind messages and whether they lead to fulfillment or frustration
of desired wishes. This is heuristic in that, to cite the example in Evans’
book, looking out an airplane’s window and seeing the engine on fire will
typically leads to fear; however, when coupled with the thought “we’re all
going to die,” emotion will certainly be amplified, even to panic. Since words
are not neutral and many words have a connotative bias, changing words
should logically lead to changes in appraisal, attribution, and affect.
It is clear that there are relationships between thoughts and feelings and
occasionally between thoughts and actions. Thoughts can mediate other
thoughts, thoughts can mediate actions, and actions can in turn mediate
and alter thoughts and feelings. There are clear relationships between thinking
and doing but they are not linear.
Evans covers the training of positive self-talk in an interesting fashion.
Teaching self-talk to individuals who have poor impulse control, inattention,
and hyperactivity can be beneficial. However, Evans notes that in some studies,
teaching students to say “it does not matter if I do not do well” actually
increases anxiety and leads to a decrement in performance. Thoughts and
some self-talk can have a positive influence on future actions by clarification
of future goals and values and therefore focusing motivation on current
activities. Thinking, acting, and emoting, even though covered by separate
chapters, are intimately intertwined and the reality is thoughts influence
behavior, in part by influencing feelings, and that behavior also influences
thoughts. The core CBT idea that words can have a very direct impact is
heuristic and clinically useful, even though incomplete.
Evans muses that thoughts are changed through what may be a common
mechanism, that being new social interaction and experience that expose
the individual to ideas that have to be understood, coupled with the acquisition
of (new) words so that the understanding can be shared. Thoughts
can be changed through Socratic argument; persuasion; presentation of
new compelling information; exposure to media influences; through popular
culture; teaching; and through the influence of occupations, family, and many
other factors, both external and internal.
Extreme forms of thought change such as brainwashing (as it is used in
cults) is typically mediated by tying together coincidence and chance events
within an (often delusional) framework; the presentation of beliefs as dogma
that are irrefutable; repeatable clichés that become a regular part of social, verbal
discourse; and the demand for purity and conformity with the ideological
thinking. Such beliefs often provide individuals with certainty, security, and
unity—all strong factors which marshal to preserve such indoctrination.
Interestingly, as therapists, we have far less potent mediators at our disposal.
The primary goal of psychotherapy is durable change and, from a CBT standpoint,
change to an individual’s internal narratives. CBT therapists aim to
change content as well as to change process as it pertains to interpreting
and making meaning of external and internal events. Evans notes that “it is
not so much the thoughts as the thinking that must change: the manner in
which errors of thought production result in distortions of reactions.” The
various strategies of CBT focus on how therapists go about trying to alter
the related notions of content and process.
In his closing chapter, “Can Cognitive Treatments Be Enhanced,” Evans
points out that many therapists share the same cognitive distortions and
errors as the individuals they aim to assist. He explains that the goal of
CBT is not to alter all unhelpful thoughts but to organize thinking such that
it serves the individual’s purpose of possible goal acquisition rather than
derailing them with negative emotion and less than optimal activity. In this
context, Evans notes that the therapeutic relationship is a structure that
enables positive verbal influence over other individuals. Evans introduces
what has been called “pathology congruent information processing bias” in
that different syndromes tend to have a cluster of unified cognitive distortions
and that an understanding of these united biases becomes an important
element in functional treatment. Evans takes this concept, weaving it into
a discourse on improving assessment and enhancing treatment. He reviews
when not to ask questions but to just listen or reflect. He reiterates fast versus
slow thought systems (covered in an earlier chapter) and how knowledge
of these dual processes can enhance treatment. So-called fast thinking is
often driven by hidden emotions emerging from past experience occasionally
associated with little insight into either the feelings or the thoughts
that emerge. He speaks about dealing with cognitive inflexibility and
close-minded individuals, noting that the status and source of new or contradictory
information is an important variable. He explains developing a preparatory
set and how this can be applied positively in different treatment
contexts. He explains that many individuals have a strong need to avoid
anxiety which is often secondary to uncertainty. Enhancing openness to
experience is addressed together with assessing the need for order and the
intolerance of ambiguity. Therapists may need to understand the function
of irrational thoughts as well as their presence. Counter arguments, when
presented without awareness of some of the above variables, can simply lead
to increased opposition and resistance rather than increasing therapeutic
change. The book ends with an important section on individualizing
cognitive therapy and making therapy more memorable. Evans stresses the
need to be especially interested in why thoughts do not change. Two client
illustrations are provided followed by an ending section titled “reflection.”
Evans stresses that insight does not inevitably lead to change. It is the human
trait of sense making that leads us into the many pitfalls of cognitive
distortions and move us toward the varied and ubiquitous biases that
humans are subject to. Helping people out of these cognitive–emotional traps
is what CBT is all about.
When doing a book review I first read the book and make annotations
of important statements and concepts. Every now and then, and this book is
a prime representative, almost every page has indicators of importance and,
in some cases, whole pages and series of pages are so annotated. This review
just barely skims the surface of this highly important, intensely well
thought out and important book. As I noted with my review of How and
Why People Change, this book, How and Why Thoughts Change, should be a
required one-two combination in every graduate clinical program dealing with
provision of psychotherapy, psychotherapy theory, or exploration of learning
and learning theory. It is very thought-provoking, clear, thorough, and well
done. It’s $59.95 cost is well worth the cognitive stimulation that it provides.
The good news is that it can be found online at significant discount. Both this
book and Evan’s previous book are highly recommended.
References
Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and commitment therapy
as a unified model of behavior change. The Counseling Psychologist, 40, 976–1002.
76 BOOK REVIEWS
Downloaded by [Massey University Library] at 16:30 02 April 2016
Kazdin, A. E. (2001). Progression of therapy research and clinical application of treatment
require better understanding of the change process. Clinical Psychology: Science and
Practice, 8, 143–151. doi:10.1093/clipsy.8.2.143
Staats, A. W. (1983). Psychology’s crisis of disunity. New York, NY: Praeger.
Howard A. Paul, PhD, ABPP
Book Review Editor
http://dx.doi.org/10.1080/07317107.2016.1135701