It is well-established that activity in the amygdala and other parts of the limbic system, which assign emotional significance to incoming sensory stimuli, is initially independent of cortical input (e.g., the influence of negative beliefs). Direct pathways through the thalamus light up the amygdala in half the time required for signals to reach this structure indirectly via thalamo-cortical pathways.
Thus, affective responses often occur before any integrated cognitive processing does. Previous overwhelming experiences are stored haphazardly by a stress-impaired hippocampus as unintegrated sensory-affective fragments. These can operate unconsciously to further distort the cognitive functioning that does eventually occur. As Shean (2001) stated:
A depressed patient may be responding at an affective level to inner somatic and outer stimuli that have not been contextualized or organized but represent unrecognized elements of previous experiences. These affective reactions can occur independently of any form of cortical processing.
I believe this is exactly what was happening when my young patient overdosed.
In sum, while beliefs can influence emotions, neuroscience says that the bulk of the influence is in the other direction. Psychodynamics has said this all along.
Turning from the demands of neuroscience to those of ordinary logic, we find cognitive therapy equally wanting. It simply labels as irrational any inference patients may make that does not conform to the most optimistic possibility! Ignoring the patient's history and arrogating to itself the power to judge what is or is not a realistic conclusion to draw from that history, cognitive therapy, in the words of Fancher (1995), "lends the authority of the therapy industry to positive illusions."
Of course, any good general psychotherapist, regardless of their theoretical orientation, will try to highlight neglected possibilities, to challenge black-and-white thinking, to encourage "shifts of set" when appropriate and indicated. But there is something obscene about the image of a young, inexperienced trainee reducing the problems of--for example--a 60-year-old minority woman who has lived a life of abandonment, abuse and economic deprivation to three columns on a blackboard and presuming to correct the "errors" in her thinking. Fortunately, many trainees have the presence of mind and the compassion to wake up to what they are being told to do. For, as one patient of mine memorably said of her brush with cognitive therapy: "People have been telling me how to think all my life!"
With its error-correcting stance, it is apparent that cognitive therapy is not rejecting transference. Instead, it is trying to hold transference constant in a benign authoritarian form and hoping to forget about it. Time and again I see puzzled therapists wondering why things aren't going according to plan when patients sabotage their authority!