Nov 8 JDN 2459162

I have been a patient in cognitive behavioral therapy (CBT) for many years now. The central premise that thoughts can influence emotions is well-founded, and the results of CBT are empirically well supported.

One of the central concepts in CBT is cognitive distortions: There are certain systematic patterns in how we tend to think, which often results in beliefs and emotions that are disproportionate with reality.

Most of the cognitive distortions CBT deals with make sense to me—and I am well aware that my mind applies them frequently: All-or-nothing, jumping to conclusions, overgeneralization, magnification and minimization, mental filtering, discounting the positive, personalization, emotional reasoning, and labeling are all clearly distorted modes of thinking that nevertheless are extremely common.

But there’s one “distortion” on CBT lists that always bothers me: “should statements”.

Listen to this definition of what is allegedly a cognitive distortion:

Another particularly damaging distortion is the tendency to make “should” statements. Should statements are statements that you make to yourself about what you “should” do, what you “ought” to do, or what you “must” do. They can also be applied to others, imposing a set of expectations that will likely not be met.

When we hang on too tightly to our “should” statements about ourselves, the result is often guilt that we cannot live up to them. When we cling to our “should” statements about others, we are generally disappointed by their failure to meet our expectations, leading to anger and resentment.

So any time we use “should”, “ought”, or “must”, we are guilty of distorted thinking? In other words, all of ethics is a cognitive distortion? The entire concept of obligation is a symptom of a mental disorder?

Different sources on CBT will define “should statements” differently, and sometimes they offer a more nuanced definition that doesn’t have such extreme implications:

Individuals thinking in ‘shoulds’, ‘oughts; or ‘musts’ have an ironclad view of how they and others ‘should’ and ‘ought’ to be. These rigid views or rules can generate feels of anger, frustration, resentment, disappointment and guilt if not followed.

Example: You don’t like playing tennis but take lessons as you feel you ‘should’, and that you ‘shouldn’t’ make so many mistakes on the court, and that your coach ‘ought to’ be stricter on you. You also feel that you ‘must’ please him by trying harder.

This is particularly problematic, I think, because of the All-or-Nothing distortion which does genuinely seem to be common among people with depression: Unless you are very clear from the start about where to draw the line, our minds will leap to saying that all statements involving the word “should” are wrong.

I think what therapists are trying to capture with this concept is something like having unrealistic expectations, or focusing too much on what could or should have happened instead of dealing with the actual situation you are in. But many seem to be unable to articulate that clearly, and instead end up asserting that entire concept of moral obligation is a cognitive distortion.

There may be a deeper error here as well: The way we study mental illness doesn’t involve enough comparison with the control group. Psychologists are accustomed to asking the question, “How do people with depression think?”; but they are not accustomed to asking the question, “How do people with depression think compared to people who don’t?” If you want to establish that A causes B, it’s not enough to show that those with B have A; you must also show that those who don’t have B also don’t have A.

This is an extreme example for illustration, but suppose someone became convinced that depression is caused by having a liver. They studied a bunch of people with depression, and found that they all had livers; hypothesis confirmed! Clearly, we need to remove the livers, and that will cure the depression.

The best example I can find of a study that actually asked that question compared nursing students and found that cognitive distortions explain about 20% of the variance in depression. This is a significant amount—but still leaves a lot unexplained. And most of the research on depression doesn’t even seem to think to compare against people without depression.

My impression is that some cognitive distortions are genuinely more common among people with depression—but not all of them. There is an ongoing controversy over what’s called the depressive realism effect, which is the finding that in at least some circumstances the beliefs of people with mild depression seem to be more accurate than the beliefs of people with no depression at all. The result is controversial both because it seems to threaten the paradigm that depression is caused by distortions, and because it seems to be very dependent on context; sometimes depression makes people more accurate in their beliefs, other times it makes them less accurate.

Overall, I am inclined to think that most people have a variety of cognitive distortions, but we only tend to notice when those distortions begin causing distress—such when are they involved in depression. Human thinking in general seems to be a muddled mess of heuristics, and the wonder is that we function as well as we do.

Does this mean that we should stop trying to remove cognitive distortions? Not at all. Distorted thinking can be harmful even if it doesn’t cause you distress: The obvious example is a fanatical religious or political belief that leads you to harm others. And indeed, recognizing and challenging cognitive distortions is a highly effective treatment for depression.

Actually I created a simple cognitive distortion worksheet based on the TEAM-CBT approach developed by David Burns that has helped me a great deal in a remarkably short time. You can download the worksheet yourself and try it out. Start with a blank page and write down as many negative thoughts as you can, and then pick 3-5 that seem particularly extreme or unlikely. Then make a copy of the cognitive distortion worksheet for each of those thoughts and follow through it step by step. Particularly do not ignore the step “This thought shows the following good things about me and my core values:”; that often feels the strangest, but it’s a critical part of what makes the TEAM-CBT approach better than conventional CBT.

So yes, we should try to challenge our cognitive distortions. But the mere fact that a thought is distressing doesn’t imply that it is wrong, and giving up on the entire concept of “should” and “ought” is throwing out a lot of babies with that bathwater.

We should be careful about labeling any thoughts that depressed people have as cognitive distortions—and “should statements” is a clear example where many psychologists have overreached in what they characterize as a distortion.