COGNITIVE BEHAVIORAL THERAPY:MODELING, RATIONAL RESTRUCTURING

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Clinical Psychology (PSY401)

Lecture 34

COGNITIVE BEHAVIORAL THERAPY

BACKGROUND:

Behavior therapy was largely dominated by terms and concepts such as behavior modification, systematic

desensitization, operant, shaping, token economies, and aversive conditioning. But this is no longer true.

We now find coverage of concepts and terms such as cognitive-behavior modification, cognitive restructur-

ing, stress inoculation, and rational restructuring. The change signifies a cognitive orientation in behavior

therapy that has overtaken the field in recent years (Hollon & Beck, 1994).

A cognitive perspective on clinical problems emphasizes the role of thinking in the etiology and

maintenance of problems. Cognitive-behavioral therapy seeks to modify or change patterns of thinking that

are believed to contribute to a patient's problems. These techniques have a great deal of empirical support

(Smith et al., 1980; Hollon & Beck, 1994) and are seen as among the most effective of all psychological in-

terventions. For example, cognitive-behavioral treatments dominate the most recent list of examples of

empirically supported treatments (Chambless et al., 1998).

Although several effective treatments based on traditional behavioral learning principles had been

developed, by the early 1970s it was clear that a number of frequently encountered clinical conditions (such

as depression) were not so easily addressed by treatments based on classical or operant conditioning Thorpe

& Olson, 1997). In a sense, the present blending of behavioral and cognitive methods was stimulated by the

limitations of both psychodynamics and radical behaviorism. This blending was also facilitated by the

presence of several theoretical models that incorporated cognitive variables along with the scientific and

experimental rigor so precious to behaviorists.

THE ROLE OF ROTTER'S SOCIAL LEARNING THEORY:

In particular, Rotter's social learning theory (Rotter, 1954; Rotter, Chance, & Phares. 1972) helped bridge

the chasm between traditional psychodynamic clinical practice and learning theory. It was a theory that

explained behavior as a joint product of both reinforcement and expectances. People choose to behave in

the way they do because the behavior chosen is expected to lead to a goal or outcome of some value.

The presence of such a social learning theory did at least two things for the development of behavior

therapy.

First, it produced a number of clinicians (and influenced others) who were ready to accept newer behavioral

techniques and were equipped with a theoretical point of view that could facilitate the modification of those

techniques along more cognitive lines.

Second, the theory, being both cognitive and motivational, was capable of blending the older

psychodynamically derived therapeutic procedures with the newer behavioral and cognitive approaches. By

its very presence, then, social learning theory facilitated a fusion of approaches that is still in progress. In

evaluating the relevance of this social learning theory for the practice of both traditional psychotherapy and

behavior therapy, consider the following implications discussed by Rotter (1970):

1. Psychotherapy is regarded as a learning situation, and the role of the therapist is to enable the patient to

achieve planned changes in observable behavior and thinking.

2. A problem-solving framework is a useful way in which to view most patients' difficulties.

3. Most often, the role of the therapist is to guide the teaming process so that not only are inadequate

behaviors and attitudes weakened but more satisfying and constructive behaviors are learned.

4. It is often necessary to change unrealistic expectancies; in so doing, one must realize how it was that

certain behaviors and expectancies arose and how prior experience was misapplied or over generalized by

the patient.

5. In therapy, the patient must learn to be concerned with the feelings, expectations, motives, and needs of

others.

6. New experiences or different ones in real life can often be much more effective than those that occur only

during the therapy situation.

7. In general, therapy is a kind of social interaction.

Now we will discuss a number of different cognitive-behavioral treatment approaches.

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Clinical Psychology (PSY401)

MODELING:

Albert Bandura (1969, 1971) has advocated the use of modeling, or observational learning, as a means of

altering behavior patterns, particularly in children Imitation, Modeling or observation are much more

efficient_ techniques for learning than is a simple reliance on punishment for incorrect responses and reward

for correct ones. A new skill or a new set of behaviors can be learned more efficiently by observing another

person-Seeing others perform a behavior can also help eliminate or reduce associated fears and anxieties.

Finally, through observation one can learn to use behaviors that are already part of the behavioral repertoire.

Perhaps the most widespread use of modeling has been to eliminate unrealistic fears (Bandura, Adams, &

Bever, 1977; Bandura, Jeffrey, & Wright, 1974). Phobias (especially snake phobias have been the principal

means both of demonstrating and of investigating modeling techniques. In participant modeling, for ex-

ample, the patient observes the therapist or model holding a snake, allowing the snake to crawl over the

body, and so on. Next, in guided participation, the patient is exhorted to try out a series of similar activities,

graded according to their potential for producing anxiety.

As noted by Thorpe and Olson (1997), observational learning is best and most efficient when the following

four conditions are met:

1. Patients attend to the model. Incentives may be helpful to facilitate attention.

2. Patients retain the information provided by the model. It may be helpful to use imagery techniques or

verbal coding strategies to help patients organize and retain the information provided.

3. Patients must perform the modeled behavior. It is important that the behavior be mimicked and practiced

to facilitate learning and behavior change.

4. Finally, patients must be motivated to use the behavior that is modeled. It is suggested that reinforcing

consequences be used to increase the likelihood that the modeled behavior will be used.

RATIONAL RESTRUCTURING:

Drawing on the work of Albert Ellis (1962), Goldfried and Davison 1994) accept-the notion that much

maladaptive behavior is determined by the ways in which people construe their world or by the assumptions

they make about it. If this is true, it follows that the behavior therapist must help patients learn to label

situations more realistically so that they can ultimately attain greater satisfactions. To facilitate this rational

restructuring of events, the therapist may sometimes use argument or discussion in an attempt to get

patients to see the irrationality of their beliefs. In addition to providing patients with a rational analysis of

their problems, the therapist may attempt to teach them to "modify their internal sentences." That is, patients

may be taught that when_ they begin to feel upset in real situations, they should pause and ask themselves

what they are telling themselves about those situations. In other instances, the therapist may have patients in

the therapy room imagine particular problem situations. All of this may be combined with behavior

rehearsal, in vivo assignments, modeling, and so on. Thus, rational restructuring is not a self-contained,

theoretically derived procedure, but an eclectic series of techniques that can be tailored to suit the particular

demands of the patient's situation.

A good example of rational restructuring is Ellis's (1962) rational-emotive Behavior therapy (REBT). Ellis

was clearly a pioneer in what has become cognitive behavior therapy. REBT aims to change behavior by

altering the way the patient thinks about things. Conventional wisdom often suggests that events cause (lead

directly to) emotional and behavioral problems. According to Ellis, however, all behavior, whether

maladjusted or otherwise, is determined not by events but by the person's interpretation of those events. In

the ABCs of REBT, Ellis argues that it is beliefs (B) about activating events or situations (A) that determine

the problematic emotional or behavioral consequences (C). He sees psychoanalytic therapy, with its

extreme reliance on insight, as inefficient; the origins of irrational thinking are not nearly so important as

the messages that people give to themselves.

In a sense, the basic goal of REBT is to make people confront their own illogical thinking. Ellis tries to get

the client to use common sense. The therapist becomes an active and directive teacher. Reviews of the

empirical literature suggest that REBT is an effective psychological intervention.

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STRESS INOCULATION TRAINING:

Based on his own research, which indicated that patients could use self-talk or self-instruction to modify

their behavior and that therapists could, in effect, train patients to change their self-talk, Meichenbaum

(1977) developed stress inoculation training (SIT).

SIT aims to prevent problems from developing by. `'inoculating" individuals to ongoing and future stressors

(Meichenbaum, 1996). It is designed to help individuals develop new coping skills and make full use of the

coping strategies that are already in place (Meichenbaum, 1996). SIT for coping with stressors appears on

the most recent list of examples of empirically supported treatments (Chambless et al., 1998). SIT proceeds

in three overlapping phases (Meichenbaum, 1996):

1. Conceptualization phase: First, the client is educated with regard to how certain thinking or appraisal

patterns lead to stress, other negative emotions, and dysfunctional behavior. The client is taught how to

identify potential threats or stressors and how to cope with them.

2. Skill acquisition and rehearsal phase: The client practices coping skills (for example, emotional self-

regulation, cognitive restructuring, using support systems) in the clinic and then gradually out in the "real

world" as he or she is confronted with the stressors.

3. Application phase: Additional opportunities arise for the client to apply a wide variety of coping skills

across a range of stressful conditions. In order to consolidate these skills, the client may be asked to help

others who are experiencing similar problems. Further "inoculation" procedures, including relapse

prevention and booster sessions, are incorporated during the follow-up period.

BECK'S COGNITIVE THERAPY:

Aaron Beck has been a pioneer in the development of cognitive-behavioral treatments for a variety of

clinical problems (Beck, 1991). This model of intervention entails the use of both cognitive and behavioral

techniques to modify dysfunctional thinking patterns that characterize the problem or disorder in question

(Beck, 1993). For example, depressed individuals are believed to harbor negative/pessimistic beliefs about

themselves, their world, and their future. Thus, a depressed 45-year-old man might be prone to be highly

self-critical (and often feel guilty, even when it is not appropriate), to view the world as generally

unsupportive and unfair, and not to hold much hope that things will improve in the future. The following

cognitive therapy (CT)-techniques might be used in the treatment of his depression (Beck, Rush, Shaw, &

Emery, 1979):

l. Scheduling activities to counteract his relative inactivity and tendency to focus on his depressive feelings.

2. Increasing the rates of pleasurable activities as well as of those in which some degree of mastery is

experienced.

3. Cognitive rehearsal: Have the patient imagine each successive step leading to the completion of an

important task (such as attending an exercise class), so that potential impediments can be identified,

anticipated, and addressed.

4. Assertiveness training and role playing.

5. Identifying automatic thoughts that occur before or during dysphoric episodes (for example, "I can't do

anything right").

6. Examining the reality or accuracy of these thoughts by eat challenging their validity ("So you don't think

there is anything you can do right?").

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Clinical Psychology (PSY401)

7. Teaching the patient to reattribute the "blame" for negative consequences to the appropriate source.

Depressed patients have a tendency to blame themselves for negative outcomes, even when they are not to

blame.

8. Helping the patient search for alternative solutions to his problems instead of resigning himself to their

insolubility.

AN EVALUATION OF THE BEHAVIORAL AND COGNITIVE BEHAVIORAL THERAPY:

Proponents of behavior therapy see their progress as tangible evidence of what can be accomplished when

the mentalistic, subjective, and nonscientific "mumbo jumbo" of psychodynamics or phenomenology is cast

aside. Critics, on the other hand, see behavior therapy as superficial, pretentiously scientific, and even dehu-

manizing in its mechanistic attempts to change human behavior. Indeed, these criticisms reflect many of the

"myths" about behavior therapy (Goldfried & Davison, 1994). In any case, more clinical psychologists

describe their orientation as cognitive or behavioral than any other orientation (Norcross et al-, 1997a).

We will now examine some of the strengths and limitations of the behavioral and cognitive behavioral

approaches, and then close with a summary of some of the challenges ahead.

Strengths:

In many ways, behavior therapy has changed the fields of psychotherapy and clinical psychology (Wilson,

1997). Below, we discuss several major ways that behavior therapy has had an impact.

Effectiveness:

There is ample evidence that a wide variety of behavioral and cognitive-behavioral therapies are effective

(Chambless et al., 1998; Emmelkamp, 1994; Hollon & Beck, 1994; Smith et al., 1980). In fact, behavior

therapy appears to be the treatment of choice for many disorders (Wilson, 1997). The separate effect sizes

calculated for RET, non-RET cognitive therapies, systematic desensitization, behavior modification, and

cognitive-behavioral therapy indicated that, on average, a client who received any of these forms of

behavior therapy was functioning better than at least 75% of those who did` not receive any treatment. More

recent meta-analyses have reached similar conclusions across a range of disorders. Further, the majority of

meta-analytic studies that have compared the effectiveness of behavioral or cognitive-behavioral techniques

with that of other forms of psychotherapy (such as psychodynamic or client centered) have found a small

but consistent superiority for behavioral and cognitive-behavioral methods. Clearly, these are important

treatment techniques for a clinician to master.

Efficiency:

The behavior therapy movement also brought with it a series of techniques that were shorter and more

efficient. The interminable number of 50-minute psychotherapy hours was replaced by a much shorter

series of consultations that focused on the patient's specific complaints. A series of equally specific pro-

cedures was applied, and the entire process terminated when the patient's complaints no longer existed.

Gone was the everlasting "rooting out" of underlying pathology, the exhaustive sorting out of the patient's

history, and the lengthy quest for insight. In their place came an emphasis on the present and a pragmatism

that was signaled by the use of specific techniques for specific problems. Because of its efficiency, behavior

therapy may be especially well suited for the managed care environment (Wilson, 1997).

In fact, some behavioral techniques can be implemented by Technicians who are trained to work under the

supervision of a doctoral-level clinician. Thus, not every component of behavior therapy needs to be

executed by Ph.D. personnel. Behavior therapy programs (for example, token economies) should be set up

by trained professionals, but their day-to-day execution can be put in the hands of technicians, paraprofes-

sionals, nurses, and others. This constitutes a considerable savings in mental health personnel and enables a

larger patient population to be reached than can be treated by the in-depth, one-on-one procedures of an

exclusively psychodynamic approach.

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Clinical Psychology (PSY401)

It is also worth repeating that behavior therapy is the undisputed leader in "manualizing" its treatments so

that empirically supported techniques can be administered in a standardized fashion. Not only does this

facilitate conducting research and providing effective treatment, but it also facilitates the training of future

clinical psychologists to administer these effective treatments.

BREADTH OF APPLICATION:

A contribution of major proportions has been the extension of the range of applicability of therapy.

Traditional psychotherapy had been reserved for the middle and upper classes who had the time and money

to devote to their psychological woes and for articulate, relatively sophisticated college students with well-

developed repertoires of coping behaviors who were attending colleges or universities that made counseling

services available to them at little if any cost. Behavior therapy has changed all that.

Now, even financially strapped individuals with mental retardation or a chronic mental illness can be helped

by therapy. Such persons may not rise to the level of independent functioning, but with the advent of

operant procedures and token economies, their institutional adjustment can often be significantly improved.

Not only the institutionalized have benefited from behavioral techniques. Patients at lower socioeconomic

levels with limited sophistication and verbal skills can also experience anxieties and phobias or lack

necessary problem-solving skills. In cases where lengthy verbal psychotherapies that were highly dependent

on insight, symbolism, or the release of some inner potential were likely to fail, a broad band of behavior

therapies seems to offer real hope.

CRITICISM:

1. Dehumanizing:

Among the more durable characterizations of the behavioral-movement are `'Sterile," "mechanistic,' and

"dehumanizing. To demonstrate that there is real labeling bias operating here, Wool folk, Wool folk, and

Wilson (1977) asked two groups of undergraduates to view identical videotapes of a teacher using rein-

forcement methods. The first group was told that the tape illustrated behavior modification; for the second

group, the tape was labeled as an illustration of humanistic education. A subsequent questionnaire revealed

that when the tape was described in humanistic terms, the teacher on the tape received significantly better

ratings and the teaching method depicted was seen as significantly more likely to promote learning and

emotional growth.

The use of mechanistic-sounding terms such as response, stimulus, reinforcement, and operant need not

imply that either the therapist or the method is detached, sterile, or dehumanizing. The systematic use of

learning principles and the examination of animal analogues for simple illustrations to highlight the nature

of human learning should not lead to a facile inference that behavior therapists are cold, manipulating

robots whose interests lie more in their learning principles than in their clients. It is to be hoped that with the

increasing cognitive orientation such erroneous mages will begin to fade.

Although nothing inherent in behavior therapy should lead one to conclude that it is necessarily

dehumanizing, its early history provided a few unfortunate episodes and a considerable stridency of

rhetoric. We have already commented on the use of aversion techniques that to many seemed more akin to

sadism than therapy. In addition, many early behaviorists seemed to be so obsessed with their principles and

their technology that common sense seemed to be the chief casualty. Their sometimes naive attacks on

psychodynamics and their zealous overconfidence in technology often played right into the hands of their

critics and only served to make life more difficult for their successors. In the final analysis, no technology

or set of principles is going to permit clinicians the luxury of giving up their clinical sensitivity.

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Clinical Psychology (PSY401)

2. Lack Of Inner Growth:

Behavior therapy has also been criticized as ameliorative but not productive of any inner growth. It has been

said to relieve symptoms or provide a few skills while failing to offer fulfilling creative experiences.

Although it may, alter behavior, it falls short of promoting understanding. It eaves out the inner person,

values, responsibility, and motives. Again, though not completely off the mark, such criticisms are less

appropriate for the newer cognitive emphasis in behavior therapy, an emphasis that does deal with

mediating variables such as expectancies and self-concepts--as long as these are objectively describable and

are inferred from specific stimuli and responses.

3. Little Focus On Mental Processes:

Although few behavior therapists can be said to embrace the unconscious, only the radical behaviorists still

insist on the absolute rejection of all so-called mental processes. Likewise, not many behavioral clinicians

are likely to recommend an exhaustive reconstruction of the patient's past (especially the psychosexuality of

childhood). But this is not to argue that past learning experiences have not led to the patient's current

predicament. Indeed they have. Any sensitive behavioral clinician will devote time to understanding what

those learning experiences were all about. By so doing, the clinician can better distinguish between behav-

ioral deficits and problems and can better understand how to structure present learning experiences so as to

enable patients to better cope with their problems.

4. Manipulation And Control:

One of the most volatile, emotion-laden criticisms of behavior therapy centers on the issue_ of manipulation

and control. The argument seems to be that behavior therapies represent insidious and often direct assaults

on the patient's capacity to make decisions, assume responsibility, and maintain dignity and integrity. But

patients typically seek professional assistance voluntarily, thereby acknowledging their need for help and

guidance in altering their lives. Thus, the patient does have the opportunity to accept or reject the proce-

dures offered (though this defense may not apply as well in institutional settings). Further, many behavior

therapy techniques are aimed at helping patients establish skills that will lead to greater self-direction and

self-control (Goldfried & Davison, 1994).

5. Generalization:

A particularly damaging criticism of several forms of behavior therapy concerns their effectiveness in

settings other than those in which they are conducted. In other words, do the effects of behavior therapy

programs generalize beyond the situations in which they are practiced? Again, in the interests of even

handedness, it should be pointed out that most forms of psychotherapy is subject to the same question. For

example, some patients show a marked improvement or adjustment in the psychotherapy situation even

though this adjustment fails to generalize to non-therapy settings.

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