Daniel

 The cognitive distortions and the idio¬ syncratic thought content of depressed pa¬ tients have been described by me in a previous article.2 It was suggested on the basis of clinical observation that many of the phenomena in depression may be charac¬ terized in terms of a thought disorder. This conclusion was drawn from the consistent finding of systematic errors, such as arbitrary inferences, selective abstraction, and overgeneralization in the idiosyncratic con¬ ceptualizations of the depressed patients. The present paper will present a theoretical analysis of the thinking disorder observed in depressed patients. The formulations will be limited to a few broad areas in which the relevant clinical material was considered ade¬ quate to warrant a formal theoretical ex¬ position. The discussion will be directed toward two salient problems : first, how the typical idiosyncratic content and cognitive distortions become dominant during the de¬ pressed phase; secondly, the relationship be¬ tween the cognitive organization and affects in depression. Finally, suggestions regarding the application of the theoretical formulations to psychotherapy will be presented. The main thesis to be developed is that certain idiosyncratic cognitive structures (schémas) become prepotent during depres¬ sion, dominate the thought processes, and lead to cognitive distortions. Literature on Cognitive Organizations The study of cognitive systems has re¬ ceived increasing attention during the past 15 years. The relevant psychoanalytic literature, particularly in the area of ego psychology, has been systematically reviewed and in¬ tegrated by Rapaport.14 The contemporary psychological literature on cognition has been more diverse as indicated by the disparate ap¬ proaches of writers such as Bruner,3 Festinger,5 Sarbin,16 Osgood,11 Allport,1 and Harvey and his co-workers.7 Submitted for publication Jan 7, 1964. From the Psychiatric Research Laboratories, Hospital of the University of Pennsylvania. There has been a notable lag in the applica¬ tion of the structural concepts generated by studies of normal thinking to the thinking disorder associated with various psychiatric syndromes. There have been few attempts to formulate the particular cognitive organiza¬ tions in these syndromes. A number of clinicians, however, have provided constructs which, although not explicitly defined as such, have the earmarks of cognitive structures. Among these contributions are Freud's con¬ ceptualizations of the primary and secondary processes,8 Horney's concept of the self image,8 Roger's formulation of the self-con¬ cept,15 and Kelly's theory of personal con¬ structs.9 More recently, Harvey et al T have presented a model of the conceptual systems in various forms of psychopathology, includ¬ ing depression. Definition of Schemas In conceptualizing a particular life situa¬ tion, composed of a kaleidoscopic array of stimuli, an individual has a number of alterna¬ tives as to which aspects of the situation he extracts and how he combines these into a coherent pattern. Individuals react in varying ways to a specific complex situation and may reach quite dissimilar conclusions. A partic¬ ular individual, moreover, tends to show con¬ sistencies in the way he responds to similar types of events. In many instances these habitual responses may be a general charac¬ teristic of individuals in his culture; in other instances, they may represent a relatively idiosyncratic type of response derived from particular experiences peculiar to him. In any event, stereotyped or repetitive patterns of conceptualizing are regarded as manifesta¬ tions of cognitive organizations or struc¬ tures.* A cognitive structure is a relatively en¬ during component of the cognitive organiza¬ tion, in contrast to a cognitive process which is transient. Cognitive structures have been postulated by a number of writers to account for the observed regularities in cognitive be¬ havior. Piaget's "schémas,"12 Rapaport's "conceptual tools,"14 Postman's "cate¬ gories," 13 Bruner's "coding systems,"3 Kelly's "personal constructs,"9 Sarbin's "modules," 1ß and Harvey's "concepts" 7 are examples of such postulated structures. In the present formulation, I have pre¬ ferred to employ the term schema to designate a cognitive structure because of its relatively greater usage and familiarity than the other terms. A cognitive schema has been defined by English and English 4 as "the complex pat¬ tern, inferred as having been imprinted in the organismic structure by experience, that com¬ bines with the properties of the presented stimulus object or of the presented idea to determine how the object or idea is to be perceived and conceptualized." The term is broad and has been applied to the small pat¬ terns involved in relatively discrete and con¬ crete conceptualizations, such as identifying a shoe; or to large, global patterns, such as ethnocentric prejudice, which causes one to regard the behavior of persons from another social group in an unfavorable way. In this discussion, the focus is on the broader, more complex schémas. In current usage, a schema is conceived of as a structure used for screening, coding, and evaluating impinging stimuli. In terms of the individual's adaptation to external reality, it is regarded as the mode by which the en¬ vironment is broken down and organized into its many psychologically relevant facets; on the basis of the matrix of schémas the in¬ dividual is able to orient himself in relation to time and space and to categorize and in¬ terpret his experiences in a meaningful way.7 In the present treatment the schémas are conceived as relatively stable cognitive struc¬ tures which channel thought processes, irre¬ spective of whether or not these are stimulated by the immediate environmental situation. When a particular set of stimuli impinge on the individual, a schema relevant to these stimuli is activated. The schema abstracts and molds the raw data into thoughts or cognitions. A cognition, in the present usage, refers to any mental activity which has a verbal content; hence it includes not only ideas and judgments but also selfinstructions, self-criticisms, or verbally artic¬ ulated wishes. In the formation of a cognition the schema provides the conceptual frame¬ work while the particular details are "filled-in" by the external stimuli. Since some forms of cognitive activity may proceed independently of immediate ex¬ ternal events, the schémas not only pattern the cognitive responses to external stimuli but to some extent channel the stream of as¬ sociations and ruminations, as well. Hence, the notion of schémas is utilized to account for the regularities and repetitive themes in "free associations" as well as in the reactions to environmental events. When a verbal response consists of label¬ ing and sorting discrete configurations, such as a shoe, the particular schémas utilized may be simple linguistic categories. The more abstract conceptualizations, such as an in¬ dividual's judgment of other people's atti¬ tudes towards him, involve more complicated schémas. Such schémas include not only com¬ plex taxonomic systems for classifying stimuli but also structuralized logical ele¬ ments, consisting of premises, assumptions, and even fully developed syllogisms. An in¬ dividual for example, who has the notion that everybody hates him will tend to interpret other people's reactions on the basis of this premise. Schemas such as these are involved in the inaccuracies, misinterpretations and distortions associated with psychopathology. Identification of Schemas Since the schémas are not directly ob¬ servable but are inferred from the obtained data, they may be regarded as "hypothetical constructs." As has already been noted, this construct is utilized to account for the repetitive patterns in an individual's thought content. The method for identifying these constructs will be discussed below. The most striking characteristic of the schémas is their content. The content is generally in the form of a generalization and corresponds to the individual's attitudes, goals, values, and conceptions. The content of the idiosyncratic schémas found in psychopathology is reflected in the typical chronic misconceptions, distorted attitudes, invalid premises, and unrealistic goals and ex¬ pectations.2 Frequently the operation of a particular schema may be inferred from a recurrent un¬ reasonable thought. A patient, for example, reported feeling anxious when a small poodle approached him. The thought preceding the anxiety was, "It's going to bite me." On further exploration, he realized that he con¬ sistently had a thought of this nature when¬ ever a dog approached him—irrespective of how small, tame or passive the animal might appear. In such cases, it is possible to recon¬ struct the syllogism that appears to have been applied by the patient in reaching this con¬ clusion. In the terminology of formal logic, the major premise (corresponding to the schema) would be: "All dogs that come near me will bite me." The minor premise, or special case, would be: "This object sniffing me is a dog." The conclusion, or application, would be: "The dog is going to bite me." In his actual experience, the patient does not verbalize the three separate steps in the syllogism. The entire process is compressed into the final step, or conclusion, which seems to arise automatically and does not seem to involve any cogitation or reflection. It is suggested that in this case the ex¬ ternal configuration (the dog) evokes the schema (major premise), which abstracts the specific details of the situation (minor premise) and produces the cognition (con¬ clusion). Even though the precise sequence may vary from the steps in formal logic, the derivation of the conclusion from the major premise (schema) appears to be essentially similar to that found in deductive reasoning. If the major premise is invalid, then the con¬ clusion will be invalid even though the logical operations may be flawless. Consequently, by observing a recurrent erroneous conclusion, one can infer the content of the idiosyncratic schema. This has important implications for psychotherapy as will be pointed out in a later section. The content of the schémas may be in¬ ferred in a number of ways (a) from an analysis of the individuals' characteristic ways of structuring specific kinds of ex¬ periences; (b) from the recurrent themes in his free association, ruminations, and reveries; (c) from the characteristic thematic content of his dreams; (d) from direct ques¬ tioning about his attitudes, prejudice, super¬ stitions, and expectations; and (e) from responses to psychological tests designed to pinpoint his stereotyped conceptions of him¬ self and his world. How the clinician may obtain an approxi¬ mate idea of the content of a schema is illus¬ trated in the following example. A highly intelligent patient reported that, whenever she was given a problem to solve, her im¬ mediate thought was, "I'm not smart enough to do it." In the psychotherapy interviews, she frequently experienced the same type of reaction; as, for example, when she was asked for associations to a dream. Her free associations during the interviews showed the same theme; ie, of not being smart. A scrutiny of her past history revealed that this was a habitual pattern which occurred repeat¬ edly throughout her life. The incongruity of this pattern was borne out by the fact that she was unusually successful in solving prob¬ lems. When asked directly about her concept of her own intelligence, she replied that, while all the evidence indicated she was very bright, she "really believed" she was stupid. It is noteworthy that in the manifest content of her dreams she frequently appeared as stupid, inept, and unsuccessful. In analyzing this clinical material, it may be concluded that one of the patient's char¬ acteristic modes of organizing her experi¬ ences was in terms of the notion, "I am stupid." This idea corresponds to a specific schema, which was evoked repetitively and inappropriately in response to situations relevant to her intellectual ability. Schemas In Depression The preceding paper presented a summary of the clinical observations of the idiosyncratic content and of the formal charac¬ teristics of the thinking of depressed patients. It was noted, first of all, that the patients' ideation had a heavy concentration of a few typically depressive themes. His interpreta¬ tions of his experiences, explanations for their occurrence, and predictions of the future showed, respectively, the themes of personal deficiency, self-blame, and negative expectations. It was observed that these themes occurred not only in the cognitive re¬ sponses to immediate environmental situa¬ tions but also pervaded the free associations, ruminations, and reflections. I also noted that, as the depression deep¬ ened, there was a progressive dominance of the thought content by these ideas. Almost any external stimulus was capable of evok¬ ing a depressive idea (stimulus generaliza¬ tion) and depressive conclusions were drawn from the scantiest data. These processes contributed to a gradually increasing dis¬ tortion and misinterpretation of reality. Some formal characteristics of the de¬ pressive cognitions were also noted. The conclusions, judgments, and interpretations appeared to arise automatically as though no prior reasoning was involved in their for¬ mation. The cognitions had an involuntary aspect. Even when the patient was deter¬ mined to suppress them or substitute other judgments, he was unable to do so. They also had a strong plausibility to the patient which was proportional to their implausibility to the examiner. As the depression progressed, these cognitions became more impermeable. The patient experienced in¬ creasing difficulty in viewing them objec¬ tively, considering contradictory evidence or alternative explanations, or modifying them. Certain aspects of the cognitive disturb¬ ance may be understood in terms of the proposition that in depression specific idio¬ syncratic schémas assume a dominant role in directing the thought processes. These schémas, which are relatively inactive during the nondepressed period, become progres¬ sively more potent as the depression devel¬ ops. The influence of these schémas is reflected in the increasing prevalence of  the typical depressive ideas in the thought content. If the hyperactive schémas, for example, have a content relevant to selfdetraction or personal deficiency, the result¬ ant cognitions will contain the themes of self-blame or inadequacy. The operation of the schémas will be de¬ scribed, first, in terms of how immediate en¬ vironmental stimuli are "processed" by the schémas and, secondly, in terms of the op¬ eration of these schémas in molding the stream of thought or "free associations." When one attempts to predict the response to a stimulus situation, it is apparent, as has been pointed out earlier, that there are a variety of ways in which the situation may be construed. Which of the alternative con¬ structions is made depends on which schema is selected to provide the framework for the conceptualization. The specific steps of ab¬ straction, synthesis, and interpretation of the stimuli vary according to the specific schema. Normally, a matching process occurs so that a schema evoked by a particular external con¬ figuration is congruent with it. In such a case, although a certain amount of variation may occur from one individual to another, the cognition resulting from the interaction of the schema with the stimuli may be ex¬ pected to be a reasonably accurate (veridi¬ cal) representation of reality. In psychopathology, however, the orderly matching of stimulus and schema is upset by the intrusion of the hyperactive idiosyncratic schémas. These schémas because of their greater strength tend to displace the more appropriate schémas, and the resulting inter¬ pretations will deviate from reality to a de¬ gree corresponding to the incongruity of the schema to the stimulus situation. The increasing frequency and degree of cognitive distortion as the depression devel¬ ops may be attributed to the progressive dominance of the idiosyncratic schémas. As these schémas become more active they are capable of being evoked by stimuli that are less congruent with them. As a result only those details of the stimulus situation that are compatible with the schema are ab¬ stracted and these are reorganized in such a way as to make them congruent with the schema. In other words, instead of a schema's being selected to "fit" the external details, the details are selectively extracted and molded to "fit" the schema. The result is inevitably distortion of reality. The "stream of thought" or "free asso¬ ciations" refers to the flow of ideas that occur independently of the immediate envi¬ ronmental situation. This form of ideation appears to be influenced by schémas in much the same way as the conceptualizations of immediate environmental situations. It is possible to discern in the flow of associations the same type of patterning that was previ¬ ously described in relation to the cognitive responses to external stimuli; the same themes of deficiency, self-blame, and wishes to escape appear. In this kind of ideation, the raw material of the associations are, prima¬ rily, stored constructions of previous experi¬ ences; viz memories, impressions, opinions. When the idiosyncratic schémas are espe¬ cially active as in severe depressions, par¬ ticular items congruent with the depressive schémas are selected from the stored mate¬ rial. These items then form part of the typi¬ cal depressive sequences of associations and ruminations. To illustrate this type of activity of the schémas, the following example is cited. A highly successful research scientist had a chronic attitude (schema) "I am a complete failure." His free associations were largely concerned with thoughts of how inferior, in¬ adequate, and unsuccessful he was. When asked by the psychiatrist to recall a single experience that did not constitute a failure to him, he was unable to do so. In this case, it is postulated that a schema with the content "I am a failure" worked over the raw material of his recent and past experiences and distorted the data to make it compatible with this premise. Whether the particular cognitive process was recollection, evaluation of his current status or attributes, or prediction of the future, the thoughts bore the imprint of this schema. Disruption of Intellectual Functions A cursory examination of the typical thoughts of depressed patients might lead to the observation that they are not very differ¬ ent from notions that normal people occa¬ sionally entertain and then dismiss. This fact raises certain questions: Why does the de¬ pressed patient appear to cling so tenaciously to his painful ideas in the face of contra¬ dictory evidence? Why does he appear re¬ fractory to alternative explanations of his experiences? While the various factors in¬ volved in the breakdown of certain intellec¬ tive functions (judgment, self-objectivity, reality testing, reasoning) are obscure, an attempt can be made to answer these ques¬ tions within the framework of the theory ad¬ vanced in this paper. As has been already indicated, one of the primary assumptions of this theory is that certain idiosyncratic schémas acquire an in¬ creased potency or intensity in the state of depression. It is further suggested that this intensity is substantially greater than that normally possessed by schémas. Because of this increased intensity, the cognitions result¬ ing from the interaction of these schémas with the raw material of experience tend to be unusually intense; ie, they are exception¬ ally compelling, vivid, and plausible. The other nondepressive cognitions tend to be relatively faint in comparison with the de¬ pressive cognitions. Hence, in scanning the various possible interpretations of the situa¬ tion, the depressed individual will be af¬ fected by the idea with the greatest intensity rather than by that with the greatest "truth value"; ie, the ideas with the greatest rele¬ vance to reality will be subordinate to the idiosyncratic ideas which have a far greater intensity. In the more severe states of depression, the patient appears to have lost voluntary control over his thinking processes; ie, even when he makes a determined effort to direct his focus to neutral subjects and to ward off his depressive ideas, the depressive cogni¬ tions continue to intrude and occupy a cen¬ tral position in his phenomenal field. At this stage the idiosyncratic schémas are so active that they are continuously producing the idiosyncratic cognitions.f In such severe cases, the cognitive processes may be anal¬ ogous to the processes during dreaming. When an individual is dreaming, the imagery of the dream totally occupies the phenomenal field and is accepted by the individual as real¬ ity. The individual has no voluntary control (or at most only limited control) over the content of the dream or ability to gauge its viridicality. Similarly, in severe depressions the indi¬ vidual's ability to direct or modify his thought content is drastically restricted. His ideas rather than being regarded by him as thoughts or interpretations of reality are viewed as reality. It may be speculated that in such a state, the intensity of the hyper¬ active schema is so strong that it obscures or excludes the operation of schémas involved in the process of reality testing. Even when he makes a determined effort to examine his depressive thoughts objectively, to check back on the details of the external stimuli, and to consider alternative explanations, the ideas associated with these processes are rela¬ tively weak and constantly crowded out by the much stronger depressive thoughts. Affects and Cognition My previous paper 2 presented a summary of the characteristic thoughts and affects of depressed patients, and indicated that there was a definite temporal contiguity of thought and affect. It was noted, furthermore, that there was a logical consistency between them; ie, the specific affect was congruent with the specific thought content. t In discussion of structure and process, it is dif¬ ficult to avoid the introduction of energy concepts. Such concepts are often vague and elusive and their utility and validity in personality theory have been strongly challenged. At a 1962 symposium spon¬ sored by the American Psychoanalytic Association, for example, there was sharp disagreement regard¬ ing the advisability of retaining energy concepts in psychoanalytic theory. On the other hand, the con¬ cept of energy is employed by many disparate schools of psychological theory. Floyd Allport,1 for example, utilizes energy concepts extensively in his formulation of the processes of perception and cog¬ nition.

My thesis derived from these clinical ob¬ servations, is: The affective response is de¬ termined by the way an individual structures his experience. Thus, if an individual's con¬ ceptualization of a situation has an unpleas¬ ant content, then he will experience a corresponding unpleasant affective response. As was indicated in the previous section on schémas, the cognitive structuring or con¬ ceptualization of a situation is dependent on the schema that is elicited. The specific schema, consequently, has a direct bearing on the affective response to a situation. It is postulated, therefore, that the schema deter¬ mines the specific type of affective response. If the schema, for example, is concerned with self-depreciation, then a feeling of sadness will be associated with it; if the schema is concerned with the anticipation of harm to the individual, then anxiety will be produced. An analogous relationship between the con¬ tent of the schema and the corresponding feeling will hold for the other affects, such as anger and elation. In clinical syndromes, such as depression, this relationship between cognitive process and affective response is easily identified. When the affective response appears inap¬ propriate to a particular stimulus situation, the incongruity may be attributed to the par¬ ticular schema that is evoked. Thus, the paradoxical gloom in depression results from the idiosyncratic schémas that are operative. This may be illustrated by the example of a depressed patient who wept bitterly when he received praise. His predominant attitude (schema) was that he was a fraud. Any praise or other favorable comment tended to activate this idea about himself. Receiving praise was interpreted by him as confirma¬ tory evidence of how he consistently "de¬ ceived" people. As was pointed out in my previous paper, the specific types of depressive affects are related to the specific types of thought pat¬ terns. Thus, schémas which have a content relevant to being deserted, thwarted, unde¬ sirable or derelict in one's duties will pro¬ duce, respectively, feelings of loneliness, frustration, humiliation, or guilt. The relative absence of anger among the more sevverely depressed patients, particularly in situations that uniformly arouse anger in other people, may be attributed to their tend¬ ency to conceptualize situations in terms of their own supposed inadequacies. The cur¬ rently popular explanation for the relative absence of overt anger in depression is that this affect is present, in fact intensified, in depression but is repressed or inverted. The present explanation seems to be more parsi¬ monious and closer to the obtained data. It is postulated that the dominant schémas are concerned with the idea that the depressed patient is deficient or blameworthy. Proceed¬ ing from the assumption that he is unworthy or culpable, the patient is forced to the con¬ clusion that insults, abuse, and deprivation are justifiable. Remorse rather than anger stems from these conceptualizations. The schémas that are dominant during depression tend to force the patient to regard insults, abuse, or deprivation as justifiable because of his own shortcomings or mistakes. For purposes of comparison, it may be expected that in other clinical syndromes characterized by an abnormal intensity of a particular affect there is a dominance of the cognitive patterns corresponding to the spe¬ cific affect. The anxious neurotic demon¬ strates the dominance and inappropriate use of schémas relevant to personal danger. The hostile paranoid is dominated by schémas concerned with blaming or accusing other in¬ dividuals (or external agencies) for their perceived abuse of him. The manic patient is influenced by schémas of positive selfevaluations. It could be speculated that once the idio¬ syncratic schémas have been mobilized and produce an affective reaction, these schémas are in turn affected by the affects. Hence, a circular mechanism could be set up with the schémas stimulating the affects and the af¬ fects reenforcing the activity of the schémas. Cognition and Psychotherapy The preceding formulation of a cognitiveaffective model of depression has a practical application in the psychotherapy of neurotic depressive reactions (as well as other psychoneuroses). Through the procedure of focus¬ ing on his distortions of reality and his unrealistic attitudes, the patient can loosen the grip of his erroneous ideas and sharpen his perception of reality. In this way he can become less vulnerable to the intrusions of his repetitive depressive thoughts and can formulate his experiences in a more realistic way. Consequently, the unpleasant affective consequences, such as depression, anxiety or agitation are reduced. In psychotic depres¬ sions this approach is generally blocked be¬ cause of the intensity of the depressive ideation and the loss of self-objectivity. Two complementary approaches have been used by me in applying this model to the psychotherapy of patients. The first ap¬ proach is concerned with the identification, appraisal, and corrections of the specific idiosyncratic depressive cognitions. Initially, it is important for the patient to become cog¬ nizant of the stereotyped content of his ideation. The therapist points out the high degree of selectivity of the patient's judg¬ ments; for example, out of the many ways of conceptualizing the myriad of life experi¬ ences, the patient is prone to perseverate in a few interpretations or explanations, such as the notion that a specific occurrence is in¬ dicative of a personal deficiency on his part. Concomitantly, it is important to define for the patient the major depressive themes (for example, inferiority, deprivation, selfreproach) in his conceptualizations so that he can begin to categorize his cognitions. This initial step of demarcating the depressive content helps to drive home the concept that the patient's negative thoughts are a symp¬ tom of depression and are not necessarily accurate representations of reality. The pro¬ cedure of identifying and labeling also gives him a greater detachment towards the idio¬ syncratic cognitions. In the process of recognizing the content of these cognitions, the patient usually be¬ comes aware of their formal characteristics. As he begins to view these thoughts objec¬ tively, he generally observes that they appear to be automatic; ie, they arise, as if by re¬ flex and are not the result of any deliberate attempt to assess a situation and reach a con¬ clusion through careful reasoning. A patient, for example, observed that when she ap¬ proached a task (preparing a meal, writing a letter, making a phone call), she immediately had the thought, "I can't do it." When she focused her attention on these thoughts, she realized their arbitrariness and she was able to attain some detachment towards them. It is generally possible to specify for the patient the types of situations that are likely to trigger the idiosyncratic cognitions, so that he can be prepared to deal with them when they arise. Another characteristic of these cognitions that poses a therapeutic problem is that they seem to be especially plausible to the patient. Even normal people tend to accept the validity of their thoughts and generally do not ques¬ tion them. In the depressed patient, the problem is compounded because the idio¬ syncratic cognitions seem to be especially plausible or "real." In fact, the more in¬ congruous these cognitions may appear to the therapist, the more plausible they are apt to be to the patient. It has been noted, moreover, that the more readily the patient accepts the idiosyncratic idea, the greater his affective reaction. There appears to be an interaction between cognition and affect because the converse also seems to be true; the more in¬ tense the affective state, the more credible the depressive cognitions seem to the patient. Also, when the intensity of the affect is re¬ duced, there is apt to be a diminution in the compelling quality of the cognition. A third therapeutically relevant charac¬ teristic of the depressive cognitions is their involuntary quality. In the more severe cases, particularly, it is apparent that these cogni¬ tions continuously invade the phenomenal field and the patient has little power to ward them off or focus his attention on something else. Even when he is determined to think about a situation in a rational manner and make an objective judgment, he is apt to be distracted by the relentness intrusions of the depressive cognitions. This perseverating and compelling quality of the depressive cognitions may be so strong as to make any form of insight psychotherapy fruitless. After the patient has become experienced in recognizing the idiosyncratic content and other characteristics of the cognitions, the therapeutic work consists of training him to evaluate their validity or accuracy. This procedure consists essentially of the applica¬ tion of the rules of evidence and logic to the cognitions and the consideration of alterna¬ tive explanations or interpretations by the pa¬ tient. In examining the validity of the cognition, the patient learns to make a distinc¬ tion between "thinking" and "believing"; ie, simply because he thinks something does not, ipso facto, mean he should believe it. Despite the apparent sophistication of the patient, it is necessary to point out that thoughts are not equivalent to external reality and, no matter how convincing they may seem, they should not be totally accepted unless validated by some objective procedure. In the interest of practicality, however, only those thoughts that have the typical depressive content are sub¬ jected to this kind of authentication. The validation of the patient's interpreta¬ tions and judgments consists, first of all, in checking the accuracy and completeness of the initial observations. On reflection, the pa¬ tient frequently discovers that either his original impression of a situation was distorted or that he jumped to a conclusion too quickly and thus ignored or rejected cer¬ tain salient details that were not compatible with this conclusion. A professor, for ex¬ ample, was downcast and complained that he was "slipping" because "nobody showed up" for a lecture. On re-examining the evidence, he realized that this was his initial impression but that in actuality most of the seats in the lecture hall had been filled. Having made an incorrect preliminary judgment, he had failed to correct it. Secondly, the logic of the pa¬ tient's conclusions should be examined. It may be found that the derivation of a partic¬ ular conclusion runs completely afoul of the rules of logic. Very frequently the major premise is invalid, although the logical opera¬ tions proceeding from this premise may be acceptable. The subject of major premises and assumptions will be discussed more fully when the second approach is outlined. Once the patient has established that a particular cognition is invalid, it is important for him (or the therapist) to neutralize its effects by stating precisely why it is inaccu¬ rate, inappropriate, or invalid. The patients in this study found that by verbalizing to themselves the reasons why a particular idea was erroneous they were able to reduce its in¬ tensity and frequency and, also, were less up¬ set by it. A depressed patient, for instance, found that no matter how fastidiously she cleaned a drawer or closet, she got the thought it was still dirty. This made her feel discouraged until she started to counter the thought with the following rebuttal: "I'm a good housekeeper—which I know and other people have told me. There's absolutely no sign of dirt. It's just as clean as it ever is when I'm not depressed. There may be a few specks of dust but that's not dirt." On an¬ other occasion, when she started to prepare a roast, she had the thought, "I won't be able to do it." She reasoned the problem through and verbalized to herself, "I've done this many times before. I may be a little slower than usual because I'm depressed, but I know what to do and if I think it out step by step there's no reason why I can't do it." She felt heartened after this and finished preparing the meal. Another method of neutralizing the in¬ accurate negative interpretations is the con¬ sideration of alternative explanations. A patient, for instance, who was exceptionally personable and popular, would characteris¬ tically interpret any reduction of enthusiasm toward her as a sign of rejection and also as evidence that she was unlikeable. After some training in dealing with her idiosyncratic cognitions, she reported the following in¬ cident. She had been conversing on the tele¬ phone with an old friend when the friend said she had to hang up because she had a beauty parlor appointment. The patient's im¬ mediate thought was "She doesn't like me," and she felt sad and disappointed. Applying the technique of "alternative explanations," she countered this with the following: "Marjorie has been my friend for many years. She has always shown that she likes me. I know she has a beauty parlor appoint¬ ment today and that is obviously the reason why she had to hang up." Her initial in¬ terpretation was part of a stereotyped pattern and excluded the proffered explanation. When the patient reviewed the episode and considered the possible explanations, she was able to accept her friend's explanation as more probable than her automatic interpreta¬ tion. Whereas the first approach deals directly with the specific judgments and expectations, the second approach is directed towards the patient's underlying chronic misconceptions, prejudices, and superstitions about himself and his world. Allied to these are the assump¬ tions basic to the way the individual sets goals, assesses and modifies his behavior, and explains adverse occurrences; these assump¬ tions underlie the injunctions, debasements, criticisms, punitiveness, and blame the pa¬ tient directs to himself. The aim to modify these chronic attitudes and patterns (schémas) is based on the concept that they determine, in part, the content of the individual's cognitions. It should follow that a basic modification or attenuation of these schémas would modify the way he organizes and in¬ terprets specific experiences as well as how he sets his goals and goes about achieving them. As indicated in the section on the identifi¬ cation of schémas, the content of the chronic attitude may be readily inferred from the examination of the recurrent themes in the patient's cognitive responses to particular situations and in his free associations (themes of personal deficiency, debility, and hopeless¬ ness). Further information about his basic premises and assumptions may be obtained by asking him what he bases a particular con¬ clusion on, or his reasons for a specific judg¬ ment. Also, an inquiry into his values, opinions, and beliefs will yield confirmatory data. Some idea of the schémas used in ap¬ proaching his problems or attaining goals may be obtained by an examination of his self-instructions and self-reproaches. One of the useful features of this approach is that it attempts to correct the major premises or as¬ sumptions that form the basis for the deduc¬ tive thinking. Since the predominance of deductive (as opposed to inductive) thinking is an important determinant of the cognitive distortions in depression, any correction of the invalid major premises will tend to reduce accordingly the erroneous conclusions. The desirability of the more inductive investiga¬ tion of reality is indicated in the first ap¬ proach which attempts to validate conclusions against the available evidence. Illustrative of the typical assumptions and premises underlying the cognitive distortions in depression are ideas such as the following: "It is very bad to make a mistake." "If any¬ thing goes wrong, it's my fault." "I'm basically unlucky and bring bad luck to my¬ self and everybody else." "If I don't continue to make a lot of money, I will go bankrupt." "I really am quite stupid and my academic success is the result of clever faking." "Trouble with constipation is a sign of disin¬ tegration." This second approach to cognitive re¬ organization is best carried out during the re¬ covery phase or when the patient is asymptomatic. The writer has noted that when substantial work has been done in modifying the maladaptive attitudes, they seemed to be far less potent even if there is a recurrence of the depression and the re¬ current depression, itself, is generally milder. Summary I have presented a cognitive-affective model of depression based on systematic clinical observations of 50 depressed and 31 nondepressed patients during psychotherapy. It was postulated that the characteristic thoughts and affects of depression are de¬ termined by persistent cognitive patterns, designated as schémas. The schémas are at¬ titudes, beliefs, and assumptions which in¬ fluence the way an individual orients himself to a situation, recognizes and labels the salient features, and conceptualizes the experience. The idiosyncratic schémas in depression consist of negative conceptions of the in¬ dividual's worth, personal characteristics, performance or health, and of nihilistic ex¬ pectations. When these schémas are evoked they mold the thought content and lead to the typical depressive feelings of sadness, guilt, loneliness, and pessimism. The schémas may be largely inactive during the asymptomatic periods but become activated with the onset of depression. As the depression deepens, these schémas increasingly dominate the cognitive processes and not only displace the more appropriate schémas but also disrupt the cognitive processes involved in attaining self-objectivity and reality testing. It is sug¬ gested that the affective reactions may facilitate the activity of these idiosyncratic schémas and, consequently, enhance the downward spiral in depression. The relative absence of anger in depression is attributed to the displacement of schémas relevant to blaming others by schémas of self-blame. The application of this conceptual model to psychotherapy consists, first, in an attempt to shift the patient's mode of judging himself and his world from an exclusively deductive to a more inductive process; ie, to form his judgments more in terms of objective evi¬ dence and less on the basis of biased assump¬ tions and misconceptions. This approach consists initially of a precise pinpointing and discussion of the patient's distortions and illogical conclusions. Then, an attempt may be made to correct his erroneous judgments by focusing on the nature of his observations and logical operations and by the considera¬ tion of alternative hypotheses. Secondly, the patient's systems of premises and assump¬ tions are examined to determine their validity. By correcting the underlying misconceptions and biased assumptions, the patient is enabled to proceed from a more realistic basis in forming his specific judgments.