An Interview with Psychologist Norman Cotterell
Dr. Cotterell is a Senior Clinician at the Beck Institute and specializes in the use of cognitive behavioral therapy (CBT).
Jennifer Ghahari: Hey, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, Research Director at Seattle Anxiety Specialists. I'd like to welcome with us psychologist, Norman Cotterell. Dr. Cotterell is a Senior Clinician at the Beck Institute and specializes in the utilization of cognitive behavioral therapy. Before we get started, can you please let us know a little bit more about yourself and what made you interested in CBT?
Norman Cotterell: Oh, wow. I think it happened by accident because before my first day in graduate school, and this is like Beckian cognitive therapy, because really I went to college interested in geology and musical theater, and then I took the psychology class in freshman year where they showed... Remember that video where they showed Albert Ellis and Fritz Pearls and Carl Rogers seeing the same person?
Jennifer Ghahari: Yes.
Norman Cotterell: This is black and white movie. And that probably was my first introduction was, something in the CBT realm was seeing Albert Ellis in action with that individual. And then later on, I became a major in psychology and I was told you had to do that. And I was told early on, I was told back in 1978 in the psychology program, which had no clinical advisor until my junior year. In fact, my supervisor or advisor when I was an undergraduate, called psychotherapy, "Oh, you're interested in the talking cure." So it wasn't exactly pushing psychotherapy at that point.
They finally hired a clinical advisor, my junior year in college. And he told me basically the only version of therapy that he considered that had a future, was worthwhile, was in the CBT realm.
Jennifer Ghahari: Wow.
Norman Cotterell: Yeah. And that was in 1978. The guy was prescient, if anything else. And so I went to University of Delaware and I think right before my very first class, the weekend before classes started, I wandered into, I guess, Art Freeman giving an all day workshop in CBT.
Jennifer Ghahari: Oh, wow.
Norman Cotterell: He said, "Oh, come on, have a seat, come on in," and sat in. So before my very first class in graduate school, I sat in on a workshop on Beckian CBT.
Jennifer Ghahari: Wow.
Norman Cotterell: Cognitive therapy at that point. And so that was in the back of my mind ever since. And I got my chance to do my postdoctoral fellowship there in 1989 and I've been here ever since. It's been a 32-year postdoc. It's a pretty simple career trajectory, basically that was it.
Jennifer Ghahari: It was the right fit. Yeah.
Norman Cotterell: Yeah. It was absolutely the right fit. And even my last lecture in undergraduate was Viktor Frankl. It was standing-room only, I literally sat at his feet while he was talking about his experience at Auschwitz, where I remember him saying the two things enabled him to survive was what's intact. Number one, finding a reason for living. And at that point his only reason for living was to find a reason for living. The only thing gave him meaning was to search for meaning. The only thing gave him purpose was that search for purpose. And the other thing was maintaining a sense of humor. Said he's not going to let the Nazis take that away from him.
Jennifer Ghahari: Oh, wow.
Norman Cotterell: Yeah. That maintained him. So those experiences got me on this path and I've been with Beck’s since 1989 and that's basically my journey. And just in working on projects after that, I mean, I got thrown into a panic disorder study as soon as I got there. And then, there were protocol therapists for studies involving generalized anxiety disorder, refractory depression, bipolar crack cocaine addiction, later on a health psychology project involving camping out in primary care physician offices. So I saw people with positive HIV status or AIDS with end-stage diabetes, with chronic pain, cancer treatments and so forth. End-stage life issues - seeing people who were terminally ill. And I did that for a couple years before I transferred. It was back in '96 when I transferred in-house from the Center for Cognitive Therapy to the Beck Institute. But same folks because in '94, Beck took half the staff moved them to Bala Cynwyd when I stayed at Penn. And then two years later I traded places with a fellow who went back to Penn from the Beck Institute. And I went from Penn to the Beck Institute.
Jennifer Ghahari: Nice.
Norman Cotterell: But we're basically sister clinics.
Jennifer Ghahari: Right. Yeah. That's great. So obviously, you know what you're talking about when it comes to CBT, which is...
Norman Cotterell: I'm still learning here. (laughing) We're all students, you know?
Jennifer Ghahari: Exactly.
Norman Cotterell: Yeah.
Jennifer Ghahari: So on that note, many of our clients reach out to us specifically requesting CBT because they've heard of it, they read a little bit about it, someone's recommended it to treat what they're experiencing... And so can you explain what is CBT and what type of issues can it used to treat? I know you just mentioned a few of them, but in general what's it used for?
Norman Cotterell: Well, yeah. I mean, goes all the way back to Greek slave philosopher Epictetus. The idea that he had is that it's not the situations that make us feel the way we do, it's our beliefs about them. So it's the thoughts and beliefs that create or enable people to interpret situations that give rise to specific emotions. Probably the most important question he asked initially is, "When you experience said emotion triggered by said experience, what was running through your mind? What words, images and pictures are running through your mind?"
That gives a clue as far as your interpretations and your beliefs that may underlie those particular thoughts. As far as experiences, the experiences can be internal. They can be external, they can be interpersonal. You can have beliefs rising from physical sensations, beliefs rising from urges, beliefs being triggered by intrusive thoughts. I see as being the internal experiences can reflect body belief and behavior. Body is manifested in sensations. Belief is manifested in thoughts and behavior is manifested in urges.
So I'd say sensations, thoughts and urges can serve as triggers for activating beliefs, which can exacerbate those sensations, exacerbate those thoughts if they get triggered and exacerbate those urges as well. And then external triggers, things you see smell, taste, touch, or do, what people do with you, in front of you, circumstances that are external to you, interpersonal things that people say to you and your relationships with people can all trigger or activate particular beliefs, which can account for how we react to those situations. And of course it goes down in a circle because you can have beliefs about your reactions as well, so it can spiral up that way.
Jennifer Ghahari: And so what type of issues can CBT treat?
Norman Cotterell: Yeah. Well, Beck started off just really focusing on depression. I mean, you might know that oddly enough his version of CBT started with dream analysis. There's been pushback on this whether in fact that was the case, but really by his telling of it, he was doing a dream analysis to look at that theory of Freud, that depression was anger turned inward. Depression, what is depression? It's anger turned inward. So he looked at the dreams of depressed people to find that theme of anger turned inward and didn't find it. What he found instead, which was not only true in dream is also true in waking life is that people tended to have a negative view of three areas in their lives: a negative view of themselves, a negative view of their personal world, a negative view of their future.
And when they saw themselves at a negative light, it triggered a bit of a hibernation instinct or hibernation response. And with hibernation, motivation goes down. With hibernation, energy goes down. With hibernation, your interest in life goes down. And as your interest, energy and motivation drops, you feel worse about yourself. You feel more inadequate, which triggers more hibernation, which can affect how you see your personal world. It colors your world the way a drop of ink would color a glass of water. And your personal world takes on a more negative light, which causes a further drop in motivation, energy and interest, which in turn makes you feel worse about your future. What kind of future is this? I don't have a future or the future is nonexistent. The future is really horrible, which can make you feel even more inclined to hibernate.
So the insights that he had, this is in his evolutionary theory of depression was that depression it's like a hibernation instinct. Depression, if there's a purpose for it is to conserve energy rather than to waste it under fruitless and useless pursuit. And depression tells us that everything is fruitless. Everything is useless. So what's the point? For you to do anything to change your life is as fruitless as a bear looking for food under 12 feet of snow, give it up, forget about it, go to your cave, curl up in a fetal position, suck your thumb, wait for the day to end, because anything you do is doom to failure. Forget about it kid, go back to your cave and hibernate, hibernate, hibernate. And what fuels that is that classic depressive triad, negative view of self, negative view of personal world. Negative view of future, which triggers hibernation, makes feeling worse about themselves, their world and their future. So it spirals down that way.
And it was interesting design for that. I mean, and there are two points of intervention. The behavioral intervention is what depression does. It's a hibernation instinct, motivation, energy, interest goes down. And the insight that Beck wrote about in cognitive therapy depression is that you don't sit around and wait for motivation to come knocking at your door. Motivation is sleeping, but there's one thing that's going to wake up motivation and that's action. You take action. If you sit around waiting for motivation knocking at your door, it's not going to happen. It won’t spontaneously say, "Hey, I'm motivation." You'll be waiting forever. You take action in the absence of motivation. And people do that with depression. There’s not supposed to be any motivation whatsoever. It's sleeping - wake it up. And it’s taking action first without the necessity, without the belief let's say that, "I have to have motivation before I can move my left pinkie. I have to have motivation before I move my foot."
Well, we do things quite often without any motivation whatsoever. We go through the motions and with depression going through the motions is brilliant. Going through the motions is a great achievement. Why? Because it is so bloody difficult. And so giving one credit for everything that you do with depression, because doing anything with depression is a sign of strength. By doing anything with depression is a sign of strength and to acknowledge that strength, give yourself credit for it. And that's a behavioral aspect and that’s our first intervention. In fact, one time I remember seeing Aaron Beck, Tim, as we called him, ATB, as we used in communication, passed away recently.
Jennifer Ghahari: I’m so sorry for your loss.
Norman Cotterell: And he's like one of my few remaining father figures. He was my academic father for the past 32 years.
Jennifer Ghahari: Oh wow.
Norman Cotterell: Yeah. It's a long time. But I saw him working with an individual who wanted to delve deep into beliefs, wanted to delve deep in terms of schema, wanted to delve deep in terms of his thoughts. And Dr. Beck told him, "You're not ready for that yet." That they were not ready for that. We need to do the behavioral work first. We need to take you off the ledge first and work behaviorally before you even touch. And that was from the father of cognitive therapy. Who's telling this guy, "We need to work on behavioral activation first." Yeah, but that is often first line of attack, do nothing-ism, behavioral activation. Really that first thing.
And then the cognitive aspect is what depression tells us. Depression is your worst best friend telling you, "Look, kid, you're crap. Your world is crap. Your future is crap. So give up." And it's a propagandist. And it's like, somebody who's printing up signs, printing up propaganda left and right. "You're crap, the world is crap. The future is crap and you're crap. The world..." And that's what it does. That's what it does for a living. That's depression doing its job. But you don't have to buy into those thoughts. You don't have to base your actions on those thoughts. In some ways there's a story from Kierkegaard where he's walking down the street, seen a sign on the shop window. Sign says, "Clothes pressed here." So he goes home, gets his clothing, plops it down the counter.
The shopkeeper says, "What are you doing that for?" Well, he said, "I saw the sign on windows says, 'clothes pressed here." And the shopkeeper says, "I don't press clothes, man. I make signs." Well, basing your actions on what depression tells you is like getting your clothes pressed at a sign making store. Depression is in the business of printing up signs. "Look, kid, you're crap. The world is crap. The future is crap. Give up. You're crap. The world is crap. Your future is crap. Give up." That's what it does. It's doing its job. But you don't have to buy into it. You don't have to base your actions on it. And as Steve Hayes, often said, "Don't believe a thing your mind tells you."
Jennifer Ghahari: Yeah, exactly.
Norman Cotterell: That would be the case where Steve Hayes council would be absolutely 100% on target, "Don't believe a thing your mind tells you." Especially when it's providing those depressive messages, where you base your behavior on, you base your actions, what's truly important in life. And if you're sitting around saying, "What's my motivation? What's my motivation?" Like a method actor. "What's my motivation? What's my motivation? Well, I can't move a finger until I know what my..." Well, far often people are depressed. Only motivation is they hate depression.
Jennifer Ghahari: That'll work.
Norman Cotterell: Yeah. That's it. But they don't even need that. They just need to move the muscles first. So that was really what cognitive therapy was designed for. What Beck designed it for was really depression and his great perspective being the depressive triad, leading to loss of motivation, energy and interest, which kind of led up back to that depressive triad negative view of self, versus the world and the future. And then they applied it to anxiety disorders. And initially it was hard to apply to anxiety because oftentimes people didn't have thoughts.
They did not have automatic thoughts with anxiety. They had strategies, they had behaviors and really they had to adapt some of the techniques of Beckian CBT to deal with people who... What's going through your mind?
Nothing. And dealing with the absence of that, which really meant that a lot of behavioral work with anxiety disorders involved identifying and eliminating people's reliance on safety behaviors and also dealing with beliefs about anxiety. As you know, very much the current wisdom is which we replicated the study from David M. Clark's group at Oxford University when I first got to Penn in 1989. Replicating the study at Oxford on panic disorder. I got thrown into that. Saw nothing but people with panic disorder when I first came to Penn. And the model that we used really had to do with individuals with panic, having a catastrophic misinterpretation of anxiety itself.
Yeah. In fact, David M. Clark, who was one of the first people I met at Penn, he was actually in resident. He was visiting there when I came, saying that was the one case where the DSM actually had a cognitive interpretation built into the guidelines for diagnosis. That is a catastrophic misinterpretation of untriggered anxiety. Only for a panic attack is having an unexpected sensation, which you catastrophically misinterpret and that gets the ball rolling. "I'm dying. I'm losing control." Either loss of physical control, loss of psychological control, either way it's catastrophic, it's immediate. And he also described the continuum between let's say panic and hypochondriasis or health anxiety as we call it now, in which with panic, you're dying now, you're losing control now, it is happening right now at this minute. Health anxiety: sometime in the future.
It's just a matter of timing. That I will eventually die, that I will eventually lose control. I will eventually... And he saw the continuum between panic and health anxiety, both involved, having misinterpretations of internal phenomena, specifically physical sensation. So we replicated the study. And so I saw people for whom their primary issue was having a catastrophic misinterpretation of physical sensations that were unexpected. And what we did was make them a bit more expected by doing panic inductions. I did panic inductions every week, with all the people I was seeing for the panic disorder study and really therapy started with the panic induction. Because that point we triggered it in-session the sensations, not really the panic attack because I was present there.
My mere presence and the fact that we did it, the fact it gave him a sense of control that there's something I did that triggered it meant that it wasn't unexpected. If you take the unexpected nature out of panic, it just doesn't have the same enthusiasm as it otherwise would have. Panic needs the element of surprise, surprise, surprise. There's no surprise that we're doing it. So as much as I did panic induction, they never really triggered panic, because we were doing something deliberately, took away the element of surprise. But what it did do, it gave them a chance to experience those very same sensations with a different interpretation of those sensations. It enabled them to have those sensations and realize and test it out that they weren't going to die.
They weren't going to lose control. They weren't going to faint for example, and that they could experience those sensations and flow through them.
Jennifer Ghahari: Wow.
Norman Cotterell: Yeah. So I got there when they were applying Beckian CBT for anxiety disorder. And then after that, we had a bipolar study in which people like Cory Newman and Mary Anne Layden and I think Susan Byers applied it to bipolar and borderline personality. They would book on that one. Cory wrote a book on bipolar and applying it to drug abuse. I worked in the project applying it to crack cocaine addiction. For a while we didn't see people with OCD, anybody with OCD we referred to Foa. She had a cognitive way of looking at it, but her procedure was very behavioral even though her conceptualization to my way of thinking was quite cognitive, but then we started seeing people with OCD. David M. Clark came up with a model for treating OCDs similar to Foa's but a tad more cognitive, I suppose, in perspective didn't necessarily involve that.
And didn't necessarily involve purely behavioral means, really Paul Salkovskis was one of the first people that I saw present on OCD, which is title of the talk was, “Why don't we all jump out of 10 story windows?” His point, being that for us, asking somebody with OCD to do exposure and response prevention, is like asking somebody to leap out a 10 story window and expect to fly. Just like doing anything constructively with depression is a sign of strength and you got to honor that, doing anything constructively with anxiety is a sign of courage. You have to acknowledge their courage. For them to do anything towards exposure response prevention and I would regularly first off ask, "What are the disadvantages of doing exposure response prevention? What are the benefits of OCD?"
Someone had an affection for OCD. There's some person I regard as being an old friend. Old worst, best friend. When I saw a presentation from a person yesterday who likened OCD to being with a lumbering dog, that gets in the way of things. But you might have some degree of affection for that dog. And there's some people, not everybody, some people that I knew also despised OCD, but some people thought they might miss it and they... I heard one person say, "Just give me a social alcoholic, you'd be a social drinker. Don't want to give up drinking entirely. Can I be a social OCD person? I do just enough to take the edge off things, but not so much that it controls my life."
I look at the benefits of OCD and look at the cost of OCD and then the benefits of exposure response prevention, because sometimes people have some ambivalence about it and so you got lay those cards on the table. And that's capturing their beliefs about the process of therapy, because you got to acknowledge the courage and the product of therapy that they might miss an old friend if they regard OCD as being a little bit of an old friend, especially since they've had it since childhood, they wonder how life could exist without it. You got to expose those beliefs as well. So we saw people with OCD and then the final frontier, where Beck thought that CBT would not apply was with psychosis. But then Kingdon and Tarkington in the UK applied it to psychosis.
They had their model, normalizing delusions, normalizing hallucinations. We all got them, basically, and agreed upon hallucination, it's called reality. And delusions, one person's belief system, can be held as delusional by another. A Protestant might regard a Catholic’s belief in transubstantiation as being a fixed delusion. By saying, "Okay, so every week you turn wine into blood and bread into flesh. Okay." And for me that was Sunday. I had 12 years Catholic education. So that was just the way that it was. But from the perspective of a Protestant, that would be a fixed delusion that Catholics have that they performed this miracle every Sunday and transubstantiation, but it does not interfere in our lives whatsoever.
And I think what they had was that people can have said beliefs and not have it interfere with their lives whatsoever. That's really the issue. And that got extended with the latest work, which Beck was working on two days before he passed away at the age of 100 and Paul Grant, Ellen Inverso, Aaron Brinen on recovery oriented cognitive therapy, CTR, which is... Really, what Beck was most enthused at in working with severe chronic mental illness, in inpatient settings, working within the milieu, working such that people can identify their aspirations and find ways to achieve and experience those aspirations, either in hospital or out of hospital.
And that's the latest. So I think he described it, every time he thought that there was a place where it'd not apply, he'd applied it to. Now granted, I saw people occasionally who were referred to me for cognitive therapy who were struggling with dementia; CBT does not cure dementia.
Jennifer Ghahari: Right. Yeah.
Norman Cotterell: That it does not. But I worked with their family members.
Jennifer Ghahari: Nice.
Norman Cotterell: I had experience in geriatrics prior to coming to the Center for Cognitive Therapy, I worked with Philadelphia Geriatric Center where I was actually working with sociologists. I interviewed people who were caregiving spouses with dementia as part of a sociology research project. I interviewed people who had put their parents, loved ones in nursing homes. And for a third study, I was starting to interview people who experienced the death of a loved one, a death study.
And I was snatched from that to work on my dissertation and then also to go to the Center for Cognitive Therapy. Yeah, so I wouldn't say that CBT is appropriate for somebody with dementia, but it certainly is appropriate for caregiver stress.
Jennifer Ghahari: Definitely makes sense, yeah.
Norman Cotterell: Although on the other hand, there may be people who are finding ways to use CBT for people with dementia. The wild thing is... Oh, I forget who was visiting us. I forget. He's a neuroscientist. (*Joseph E. LeDoux of NYU) You'll probably look him up. He has a rock band called the Amygdaloids. He's a rock musician and neuroscientist. He opened for Roseanne Cash, I think. But anyways, he's a neuroscientist primarily, rockstar by night and he was visiting us. And he was basically saying that the notion that memory is just hippocampus is not true.
He says there's memory in every single cell of the body. He says, "I could teach planaria how to do tricks. I could teach single celled creatures how to do tricks. It's not just in the hippocampus." And that was reiterated in work that was cited by Charles Duhigg's book on habits, showing that even people with dementia can learn new habits. So they’ll forget that they learned them, but they could still learn them through muscle memory.
Jennifer Ghahari: Oh, okay.
Norman Cotterell: Yeah. Or even just things that they don't forget. I remember there was one person I was interviewing and some stuff remains and maybe some stuff can also be taught, but they gave demonstration to people even with dementia being taught specific habits. So maybe the B of CBT might even find some for people's dementia. When I was interviewing a caregiving spouse one time, I thought he had the radio on because I heard music playing and music stopped and his wife came out obviously in dementia and she was playing piano purely for memory.
Jennifer Ghahari: Oh, wow, okay.
Norman Cotterell: And he said she's been playing piano since she was five years old. Everything else was gone that remained, the muscle memory remained intact and it gave her great pleasure. In fact, there was a Ted Talk about a woman whose preparation for dementia was to learn how to knit, because she had observed that there were people with dementia who had muscle memory for activities that gave him a great pleasure. Since it ran in her family, her method of preparing for dementia was to learn a skill, put it in muscle memory, so if per chance that she came with dementia, that she'd have a pleasure to engage in.
Jennifer Ghahari: It was something that she can to create. It sounds like whether it's music or knitting or something…
Norman Cotterell: Yeah. And that's assuming that the portion of the brain would not be the portion of the brain that enables her to knit because actually I interviewed another caregiving spouse, but in that case the first thing that went for that individual was her painting ability, everything else... So it depends which part of the brain is being affected by the dementia as far as whether or not you maintain or lose specific capabilities. But with the cases of the woman with piano… that remained intact.
So maybe the B of the CBT might be a frontier for even working with dementia. But Tim Beck said the anytime he thought that CBT would not apply to a certain area, some expert, some person who knows that backwards and forwards would find a way. There were people who were expert in autism, spectrum conditions who found a way to adapt CBT to work with people on the spectrum.
Jennifer Ghahari: Oh!
Norman Cotterell: Okay. That's it. There are people who specialize in addictions who found a way to adapt CBT to work with addictions. So what happens is you get people and it might be more matter of the individual rather than the techniques. Find people who work well with that population, and they may find a way. They find a way to adapt the tools from CBT into the modality they work in. So we'll see. Well actually, can you think of an area that CBT has not touched yet?
Jennifer Ghahari: No, not at this point.
Norman Cotterell: Yeah. It'll probably come to us after the interview.
Jennifer Ghahari: Exactly.
Norman Cotterell: Yeah. I'd say it's a matter of the personality of the therapist and their expertise in that particular area. Like I stay away from kids, I don't see kids under the age of 17. No, do not. But there are people who are really, really good with children. I saw one of my colleagues working with a three or four year old and I regarded that as being amazing, but that was his field of expertise. That was his comfort zone. That's what he knew as far as working with children. And he applied the tools and techniques and strategies that were geared and tailored for that population in CBT to work with children. But I say that has more to do with the characteristics of the therapist than anything else.
Jennifer Ghahari: Right.
Norman Cotterell: Yeah.
Jennifer Ghahari: So when someone goes to a therapist for CBT, what can they typically expect to happen? I know you mentioned exposure ERP for example, as one method, but what else can someone expect?
Norman Cotterell: Well, I think the first thing I do ask them about what they want to see happen from therapy. I mean, this is before I even do the diagnostic interview. Really the purpose is to give them tools, so they can be on the road to changing their life. So really I start off, the most important thing is goal setting, which is defining a direction they want their life to head into. A goal is like a terminal point, direction is like heading Northeast in the direction of health towards that direction you want to go in. And whether it's a small step or a large step, you're still heading in the right direction. So I asked him to get a sense of that. I asked them the old question from Alfred Adler.
He had the magic wand question. David Burns reframes it as a magic button question. They might regard a magic wand as being a tad in infantilizing. So now I use a magic button, that way they have control over pushing it. And so if they push that magic button and they're healed, depression is gone. You feel great about yourself. Feel great about your personal world. You feel great about your future, your energy, your motivation, your drive for life, your zest for life is back and full force. And on top of that, anxiety's not a problem. The current wisdom is that anxiety's not the problem, fear of anxiety is the problem. Well, your fear of anxiety is gone and anxiety is nothing but booster jets to get the job done. Anxiety goes from being a liability to being an asset. Anxiety goes from being a foe to being a friend, goes from being enemy troops to reinforcement and anxiety is just energy to get the job done.
You push that button. You feel great about yourself, your world, your future, your energy, your motivation is back in full force. Anxiety is just energy and whatever goals you have, they're there. If you push that button and you're totally healed, external circumstances are the same. Externals are the same, but you push that button you have a change internally. What would you do? What would change in your life? And write that down. And then I ask a second way, same question. You push that button. You feel great about yourself, your world, your future, energy, motivation back in full force. Anxiety is just energy to get the job done. What would you do in the next seven days? Next seven days what would you do?
Jennifer Ghahari: Yeah.
Norman Cotterell: Yeah. To make it more specific and sometimes might say, "Yeah, do the same thing." Well, more pep in your step, more glide in your stride." Yeah. Okay. Put that down. More energy in doing what you're already doing. Or some people might say, "Well, nothing would change. I'd just be doing the same thing I did before." And some people might say, "Well, everything would change. Everything would change." I want to know whether they say nothing would change, everything will change or somewhere in between. And then I ask it a third way. You push that button. You feel great about yourself, your world, your future energy is back and full force. Anxiety is an asset rather than a liability. What would you do for the rest of day, this afternoon, this evening, tomorrow morning, tomorrow afternoon, tomorrow night what would you do if you are totally, thoroughly and permanently healed?
And I write that down to get a sense of what their life would be like if they were not plagued with these symptoms. And then I also ask, just a matter to ask, what kind of hobbies and interest do you have? What kind of things do they enjoy? What things, give them pleasure in life? And again, aspect of what interest they have, what things they would do. What interests they have had in the past and might have in the future again, if depression or fear or anxiety were gone. And I asked them the old Steve Hayes question, "If you could be in a world of your own making what would you want your life be about? What is really, really important for you?" I want to get a sense of their values.
Now, when we first came to Penn, I got thrust in another study on values in 1989, where they just had two, sociotrophy, autonomy were the two values that you're looking at Penn back in 1989. It's been expanded since then, I mean, Russ Harris has a quick look at your values, which I think I have 63, which are a good deal more than two that we're looking at Penn. But there can be values or needs or desires based on sociotrophy connections with people or based on autonomy. Things that can be done more individually. Either way, I want to know what's really, really important to them. What is really, really key for them. Sometimes if they are students I ask if success was guaranteed and whatever you touched turned to gold - what would you do for a career? If that is an issue for them, if they still try to decide what they want to do with their lives. I think if success was absolutely guaranteed what would you do for a career or for a livelihood? If that's relevant.
That's where I start off. And then with that, we review the goals in the first session, have them add detail to that. And I asked to tell also, what do you know about cognitive therapy? And how do you think it can help you with these issues to get you where you want to be or head in the direction you want to head? And then that's where we start in using the tools, in order to focus on the specific goals that they have in life, the direction they want to head towards in life and how we can take those initial steps in that direction. And sometimes it may be depression, which is telling them, "Forget about a kid, go to your cave, curl up in a fetal position." Depression telling them that they're a bear and it's time to hibernate. Or else the impediment could be fear of anxiety, fear of anxious sensations, fear of anxious thoughts, fear of anxious urges that can get them stuck in which the cure, seemingly for anxiety it can be avoidance. For everything just avoid, but then they avoid everything.
And what happens, the byproduct of avoidance, it reduces anxiety temporarily if they avoid things that really, really matter. And then anxiety, the fear goes up. And then on top of that, if they get addicted to avoidance, it can trigger another side effect called depression. So we basically see what's getting in the way of them doing that. And so what they can expect is that I'll ask them what they want to put on the agenda or what they want to accomplish in session today. What's their goal for today's session.
And I ask them how the week went? I'm using the matter of course to capture people's aspects of the week. I'm taking from Marty Seligman on this one, on his PERMA mnemonic. Are you familiar with that one?
Jennifer Ghahari: I'm not. No.
Norman Cotterell: Yeah. It's his recipe or formula for well-being, if not happiness. First homework assignment, the first action plan I give people after the intake evaluation, after we look at the goals is... I define happiness like Oprah defines love: as behavior. It's what you do. Ok. So it can be what you do for pleasure. What you see, smell, taste, touch, hear that's pleasurable. What you do for others what other people do for you, what you enjoy vicariously that provides pleasure. And then I asked them, "What was the most enjoyable thing that you did in the past couple weeks? And what gave you pleasure?" For example, if I ask you, what was the most pleasurable thing you did in the past couple of weeks?
Jennifer Ghahari: I actually traveled. I just got back from Europe and it was amazing.
Norman Cotterell: Okay. So I write under pleasure: traveling. And then I say, there might be some things which might not create pleasure, but they engage your mind. They turn you on intellectually. So looking back in the past couple weeks, what interested you? What engaged your mind in the past couple weeks the most relatively speak?
Jennifer Ghahari: It might sound funny, but the first thing that just popped into my head was decorating for Christmas.
Norman Cotterell: Decorating for Christmas. Okay so for pleasure, it was travel, for engagement, decorate for Christmas, and there might be some things which might not create pleasure, they might not engage your mind, but they build relationships. The people you care about, the things that you do for love, either to give love, receive love, express love, anything that you did to build relations with people you care about in the past couple of weeks.
Jennifer Ghahari: Actually both of those things, the traveling and decorating for Christmas, I think.
Norman Cotterell: Yeah. Doing it for others, it could be service. And that could include words of affirmation, that could include gifts that you give to people. It could include just simple quality time you spend with people. It could include, physical touch and affection, could include acts of service. Anything like that can be those languages of love, which I just cited that people do to build relationships with people they care about and love. And then finally I say, or actually second to last, I say, there might be some things though that might not create pleasure. They might not engage your mind. They might not build relationships, but they give you a sense of meaning and purpose. And sometimes I go back to what do you want your life to be about for that one?
What do you want your life to be about for that one? And I ask, if there's anything that you did in the past week or two that gave you a sense of meaning and purpose? And sometimes it's a tough one for people. So it's really a matter of saying and identifying what they're already doing that gives them that sense of meaning and purpose. And that could be things they do for security and stability. If that's important to them, things they do for stimulation or adventure or variety in life, that's important for them. Things they do to build connections with people they care about, things they do to contribute to themselves. Things they do where they can experience, intellectual, spiritual, or growth or things that they do that provide them a sense of accomplishment or significance for that matter, feeling important, feeling valued in some ways.
Though that's a categorization of values or needs that I found in two places, one was with Cloe Madanes, she divides needs into those categories and found something similar in the works of Norman Epstein and Don Baucom in their couple's therapy book which also has lists of needs. Lists of needs, probably in those categories as well between, sociotropic needs, autonomous needs in those categories. But, it's a short step between needs and values. And Tim Beck didn't like the word needs, so he changed that word to desires. Because he said, "We’ll always need food and water." But these are more like desires than needs.
So Epstein and Baucom called them needs, I can call them the desires. If you don't like the word needs, it seems needy. So he said desires. So short step between desires and values. So we can go for that. And so that's what I capture what gives them a sense of meaning and purpose is what valued action they engage in. They're already engaging in. And so when you think about that in the past couple of weeks, what did you do in the past week or two that gave you a sense of meaning and purpose?
Jennifer Ghahari: For me, I've been learning to cook a little bit healthier. And so I think that's... And sharing that with family and that I think gives me a little bit more meaning and purpose. And speaking with you as well for this series.
Norman Cotterell: And according to that categorization provides a little spice as the variety of the spice of life. And so you add a little spice into your foods and it provides contribution because you're giving the food to others, the sense of contribution to them and it maybe even connection for that matter. And also if they complement your food, you can feel, "Oh God, that's great." And also growth in terms of your learning a new skill, learning a new ability. So it might capture a variety of desires or values that you might have. And so when I come to meaning, it's almost like having them discover what they're already doing, that they're already doing that satisfies those desires, what they're already doing that is in line with their deeper, deeper values.
And then finally back to Seligman, again, finally, there might be some things which might not create pleasure, they might not engage your mind. They might not build relationships, might not give you a sense of meaning and purpose, but they provide you a sense of accomplishment. And looking back over the past week or two, what gave you a sense of accomplishment?
Jennifer Ghahari: Ooh, honestly, I made some really good recipes.
Norman Cotterell: Okay. Okay. Yes.
Jennifer Ghahari: They came out so much better than I expected.
Norman Cotterell: Okay. So that's what I write down. For the first I say, "I write down for pleasure." Okay, let's say it can be travel, for engagement, it was learning how to cook, for relationship, the same thing. For meaning, being able to learn new things and for accomplishment, sharing the food with your family. Yeah, for meaning sharing the food with your family, learning new skills as far as what to cook and for accomplishment, the same thing. And then I asked them, at the end of the day, this is straight from Seligman as well, "at the end of the day write three things that went well." Things that you did that either provided pleasure or engaged your mind or built relationships with people you cared about or gave you a sense of meaning and purpose, or gave you a sense of accomplishment. Not three of each, please that would be 15. That's pleasure or engagement or relationships or meaning or accomplishment.
And together they spell the word PERMA, stands for pleasure, engagement, relationships, meaning, accomplishment. And that's the first thing I do. So before every session, I'm in the habit of asking, in the past week, what did you do for pleasure? What did you do that engaged your mind? What did you do for relationships? What did you do for meaning? What did you do for accomplishment?" And if they say, "I can't really think of it." That's fine, but be on the lookout. And oftentimes people might say “Nothing provided pleasure.” And if I think that's an important one, I ask, "Was there anything you saw? Come to your senses. Was there anything that you saw that gave you pleasure?"
Jennifer Ghahari: Yeah.
Norman Cotterell: "Anything that you heard that gave you pleasure. Anything you smelled." The most primitive sense, before we could do anything else, we could smell. Anything, you smell, any aromas, direct beeline to the brain. Any aromas that provided pleasure for you? Anything that you tasted that provided pleasure. Anything that you felt that provided... And usually when you come down to sensory experiences, even people who said, "Nothing was enjoyable. No pleasure whatsoever." When you break it down to the senses, nine times out of 10 they can pick out something that provided pleasure.
They could find something that provided that measure of pleasure for them. So that's what I lead off with. And then I ask, what do you want to work on problematically that you dealt with in week? Or look on the list of goals, which are these goals you want to work on first? And then just use the tools to do that. But I really start off with asking what went well, because our brains are really built to focus on what's wrong, not what's right.
We focus on what's wrong. It could eat us for lunch as if our lives depended upon that. And really what we do for growth perhaps is to update the software a little bit by having people focus on what's right. Not on the tile that is broken, but the tiles that are intact: the broken tile syndrome. We have a tendency to focus on that one tile that is broken to the exclusion all the ones that are intact. And so by doing that, I'm having them focus on the ones that are intact. That's John Kabat-Zinn’s notion that as long as you're breathing, there's something right with you. So focus on what's right, because we're really, really good at focusing what's wrong. And so just them giving equal time.
Jennifer Ghahari: Fantastic. So as a therapist specializing in CBT, would you have any other advice or recommendations for our listeners? This is the last question I always like to end with.
Norman Cotterell: Advice?
Jennifer Ghahari: Any words of wisdom or…
Norman Cotterell: Yeah, be nice, have fun. I mean, at this point I wasn't prepared for that because I'll probably say something that's going to be really, really, really trite like that. But sometimes trite things carry some weight for me. And I'll probably know exactly what it was. I'll probably email you, "This is what I should said." Words of wisdom!
Jennifer Ghahari: (laughing) We’ll put a “Part Two.”
Norman Cotterell: Well, I'm thinking of... I had an uncle who was born in the 1870s. He died of 1980s. He was a son of person who had been enslaved. And before I went to college, my uncle Willie said, "I got one word for you son, one word.” He said, “Strive. strive." So I think of my uncle Willie, as far as that word strive. But he had fun in the process, he had a lot of fun in the process of his long, long life. I mean, he lived way over 100 and went in long walks around Manhattan, read the New York Times every day and maintained that curiosity. So I think probably the other thing that I think that's really important is maintaining that spirit of curiosity. Maintain it.
Jennifer Ghahari: As you said too, also just looking for the little positives in every day, whether it's a smell or if it's something more significant.
Norman Cotterell: Yeah. And growth. My father's an amazing man. My father, he grew up with a drunken, gun toting, carousing gynecologist as a father. My grandfather immigrated this country with $7 in his pocket, worked construction when he was in divinity school, pastored a church when he was in medical school and later taught medical school at Meharry (Medical College). And then drank himself to death in 1941. My father was serving in World War II. So I regard the first Dr. Cotterell as being a cautionary tale, but his son, my father: amazing. My father barely graduated from high school, volunteered, was part of the CC camps where he built the national park system in the Pacific Northwest and Northern California and volunteered for the Navy and his first experience was Pearl Harbor. He survived that.
And I didn't find out about his heroics until after he had passed away about what he did there that he was cited for. But he hated the story told about African American soldiers being cowardly. So he made a point to put himself as many dangerous life-threatening situations as possible. He was in World War II. He was in Korea. He was a civil rights actor. He marched with Martin Luther King. Martin Luther King actually marched with him in Los Angeles with his group, Congress of Racial Equality. He was the firefighter where his job was to run into burning buildings. And my dad was a wild swimmer, take a raft in the middle of the Pacific Ocean and swim laps around it in the middle of the Pacific Ocean as well.
Amazing, amazing swimmer. I have none of his gifts in that area. And also built an addition to the house, single handedly, mad, mad, mad skills, mad skills. But at the age of 85, when he was no longer going to break any records, because he was the guy who would do twice as many pushups as guys for half his age when he was a firefighter. The one-arm’d push up, it would be my dad. And at the age of 85, he wasn't going to break any physical records, but yeah, he took piano lessons. And had a piano recital the age of 86.
Jennifer Ghahari: Oh, that's amazing.
Norman Cotterell: And so I think that is my role model really for maintaining curiosity and maintaining growth even into your 80s. And my other role model for that of course is Aaron Beck.
Yeah. Working and writing and maintaining that undying curiosity to the very, very end. Both he and my father were active, up until shortly, case of Aaron Beck two days before he passed away. Case of my father, like a month, maybe less, because my father went into the hospital thinking he would survive the surgery and got plane ticket. And this is at the age of 91, despite his best effort to lead a short and a rough life, he still lived to be 91. And at 91 he was thought to be fit enough to survive the surgery for a benign tumor. He wasn't. But he had plane tickets. He was going to have the surgery, hop on a plane, go to my niece's wedding at the age of 91, but he did not survive the surgery.
So he kept that spirit up until the end. So really when I think of my words of advice, I say seek inspiration from those people you admire the most. We all have people that we admire and they serve as role models. And we all have people who are more problematic. They're cautionary tales. And those might be people where we do the opposite of what they did. Whatever they did, the first Dr. Cotterell, he taught me about the importance of fidelity and sobriety. So that's just a good role model as far as what not to do in those areas.
And also nonviolence too. He was not exactly a peaceful guy. My father, on the other hand, absolutely a role model of what to do. So I'd say what I do is I find the people who I admire the most. I find the people who inspire me. And as much as possible I model all their actions, I learn from them. And I put into practice what they taught me. That's how I honor their memory by putting into practice what I learned from my uncle, Willie. Putting in practice, what I learned from my father and putting into practice, what I learned from Aaron Beck.
Jennifer Ghahari: That's wonderful. Thank you so much. I'm probably going to watch this interview myself about 40 more times just because I feel like I got so much out of it personally, so I'm sure our listeners will also have an amazing time listening to it. Dr. Cotterell from the Beck Institute, thank you so much for spending this time with us.
Norman Cotterell: It's certainly my pleasure.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.