Improving Prospection

If faulty prospection drives depression, then interventions should aim to fix prospection. Cognitive behavioral therapy (CBT) already has some future-oriented arrows in its quiver and these deserve to be formalized, extended, and grouped together. One can be a competent CBT therapist and focus entirely on future cognitions or ignore them altogether. CBT adherence protocols do not explicitly rate attempts to change faulty prospection. The Collaborative Study Psychotherapy Rating Scale (Hollon et al., 1988), for example, lists 32 CBT procedures; none of them explicitly target prospection and only three implicitly target prospection (setting up behavioral experiments to test beliefs, exploring realistic consequences of actions, and scheduling pleasant activities).

Here is a scenario that highlights the difference between CBT interventions that neglect prospection versus target prospection: A depressed woman has argued with her husband, and her therapist challenges her distorted, upsetting thoughts about the argument. The therapist chooses one of two interventions, both of which are classic CBT: Intervention A neglects the woman's thoughts about her future, whereas Intervention B squarely focuses on them.

In Intervention A, the therapist considers the client's automatic thoughts about the fight, and decides that this one is the most important: "He must think I'm a horrible person." (In the depressive cognitive triad, this reflects a negative view of the self.) The client and therapist identify the cognitive distortion underlying this thought (mind-reading), and then consider the evidence for and against the thought. To dispute the thought, they consider times in the past when the client's husband has said positive things about her, times when she has acted in a caring way toward him, and times when they reconciled after a fight and did not judge each other harshly. The client decides that her husband probably has a balanced and compassionate view toward her, and she feels better—for now.

This is a perfectly "adherent" cognitive intervention, but it leaves the client's faulty prospection intact. Even as the client comes to believe that her husband still loves and respects her, she is bothered by a nagging fear that it is just a matter of time before he leaves her. She disqualifies the past evidence (e.g., that he has forgiven her after past fights), saying to herself, "that was then; things will get worse this time"). She still runs if-then simulations that end with divorce, and she still imagines a sad future: visions of divorce papers, a living room filled with boxes containing her husband's belongings, and courtroom appearances about child custody. She is still deeply pessimistic, and still feels depressed whenever she runs these recurring negative simulations.

In Intervention B, which targets prospection, the therapist decides to challenge this automatic thought: "I am going to drive this relationship into the ground." (In the depressive cognitive triad, this is a negative view of the future.) The client and therapist identify the imagery tied to this prediction. They spot the cognitive distortions of fortune-telling and catastrophizing, and then consider the evidence (Beck & Weishaar, 1989; Burns, 1980). They generate other possible outcomes (e.g., reconciling, using the incident to strengthen their bond), and they review the evidence for these. They also explore actions that would lead to positive outcomes (e.g., change communication styles in couples therapy). The client decides that her marriage is not doomed and she feels better.

This, too, is an "adherent" CBT intervention, but it directly addresses the future. The best possible outcome of this intervention would be an end to the client's catastrophic predictions and imagery about her future. She considers a broader, more realistic, and more empowering array of if-then scenarios. Of course, this change will not come quickly or easily; initially such future-based interventions will likely be effortful because the client's faulty prospection is so entrenched. This is exactly why such interventions are needed, however, and in the long run, we hypothesize that these interventions will prove more protective than other cognitive interventions.

CBT therapists face many decision points during a single therapy session. Which problem should be prioritized? Which automatic thought should be targeted? If faulty prospection is indeed central to depression, then therapists should be guided by two principles when making these decisions:

  • 1. When there is a choice to work on several automatic thoughts, target the thought about the future, unless there is a compelling reason to do otherwise.
  • 2. When no dysfunctional thought about the future is immediately evident, search for it. If needed, downward arrow questions (Friedman & Thase, 2006) should be used until the underlying prospective thought is discovered.

We hypothesize that when therapists systematically and extensively target depressive prospection, then CBT will work better.

 
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