Following a period of extensive research on basic behavioral processes, and how various forms of psy-chopathology may be acquired through environmental
circumstances (learning), many investigators became dissatisfied with conditioning theory. Increasingly, behavior therapists were persuaded that the information proffered from clients' self-report was itself an appropriate area of study and that this information might form the basis of functional assessment and intervention. That is, the way clients think was offered as a causative factor in behavioral and emotional problems. Heralded as a more comprehensive view of individual clients, this adjustment was intended to augment current behavioral models by accounting for cognitive styles that are introduced into clinical settings and set the occasion for the development and/or maintenance of most forms of psy-chopathology. This was the basis for the cognitive revolution that took hold of behavior therapy and continues to exert considerable influence today. Figure 3 depicts this modification of behavioral theory.
Prior to the more formal integration into behavior therapy that cognitive interventions enjoy today, groundwork was laid that would allow for the merging of these approaches. Notable in this regard was the work of Cautela involving coverants and covert conditioning mentioned earlier. Although originally placed in the same company as other traditional behavioral interventions (such as operant and classical conditioning), it should be noted that each element of intervention was a cognitive construction, including reinforcers, consequences, and behavior (i.e., images of behavioral events). Coverant control continues to be viewed as a behavioral rather than a cognitive treatment despite the fact that the events, antecedent stimuli, and reinforcing consequences are entirely imaginal and therefore cognitive.
It is interesting that the mainstream cognitive revolution was initiated by clinicians who were neither behavioral by training, nor experimental psychologists by trade. Beck's cognitive therapy and Ellis's rational emotive behavior therapy each offered approaches to treatment that were essentially client centered, Socratic in method, and reliant on client self-report augured by client self-observation and verbal challenge of identified dysfunctional beliefs. These clinicians assert that the impetus for developing their approaches to treatment was as a reaction to their more traditional training in psychodynamic approaches, whereby they observed that clients spontaneously report a variety of negative thoughts that give rise to neurotic conditions. In contrast to their traditional training, each felt compelled not only by this observation, but by clinical experience that teaching clients methods for directly addressing these spontaneously reported thoughts resulted in the alleviation of emotional distress and behavior disturbance. Both approaches have been popularized and integrated into contemporary behavior therapy. Indeed, this integration appears so complete that most refer to this treatment approach as cognitive-behavioral therapy (CBT) rather than behavior therapy (BT).
1. Beck's Cognitive Therapy
Beck suggests that emotional distress is predicated upon negative automatic thoughts (NATs), which emerge from schemas. Schemas are defined as structures that organize information in a database-like form that sorts and summons information based on stimuli (either overt events or other verbalizations). In 1978 Beck and colleagues articulated this notion most prominently in the application of cognitive therapy for depression. Specifically, depressed individuals are said to possess a "negative triad" of automatic thoughts that cause negative views of the self, world, and future. Each of these domains has been characterized as a schema that is essentially negative in depressed individ
Self-monitoring Form for Client Use in Cognitive Therapy (Sample Form)
Date Situation Emotions Automatic thoughts Rational response Outcome uals. The principle task in cognitive therapy (CT) is to help clients systematically determine ways of challenging these thoughts, usually by evidence gathering and self-monitoring. Since the time that Beck and his colleagues described this method for treating depression, it has been extended to anxiety disorders, substance abuse, personality disorders, obsessive-compulsive disorder, eating disorders, and delusions. Beck's approach has shown a great deal of promise in alleviating emotional distress, as well as shedding light on the interaction between therapy and medication. Specifically, it has been shown in numerous trials that cognitive therapy alone is at least as effective as antidepressant medication for depression, while also showing greater maintenance of gains following medication discontinuation. This has since become an important experimental design for use in determining the relative contribution of CBT and medication for a number of other psychological conditions such as panic disorder, obsessive-compulsive disorder, alcohol abuse, and eating disorders.
Cognitive therapy, using the approach described by Beck, involves teaching clients to become their own scientist. For example, clients are engaged in a So-cratic discussion whereby the negative automatic thoughts are actively challenged. Clients are taught to identify NATs by maintaining a daily log that is structured along dimensions of situation(s), emotional response to that situation, automatic thoughts, rational response, and outcome. A sample form for client use is presented in Table 1.
The components of the strategy of monitoring events and the NATs that give rise to emotional distress are highly structured in CT. Clients are taught to identify specific situations (or imagery that occur in daydreams) that result in distressing emotional reactions. Clients are instructed in the identification of these NATs and then taught how to challenge these ideas using specific questioning of the accuracy of these ideas. They are then asked to write a rational alternative thought and the outcome from applying this alternate thought. Throughout, as a means of examining the effectiveness of the challenge, clients are also instructed to rate the degree to which they experience the emotion, as well as degree they believe both the NAT and rational alternative. Implicit in this approach is the perspective that one will not initially believe the rational alternative, but with repeated practice the underlying philosophy of the rational alternatives will begin to take hold.
In order to be effective, and for the integration of the rational alternatives to replace the NATs, Beck argues that clients must engage in personal experiments that are designed to directly challenge the accuracy of these dysfunctional thoughts. After conducting several of these experiments, practitioners applying CT seek to identify "themes" (schemas) that guide these automatic thoughts. It is at this point that the cognitive therapist begins to actively challenge the underlying theme, instruct clients to seek situations that broadly address these themes, and continue monitoring automatic thoughts as a means of identifying other possible automatic thoughts that may arise as treatment continues. Broadly speaking, this process has been referred to as cognitive restructuring.
2. Ellis's Rational Emotive Behavior Therapy (REBT)
Ellis has described a variant of CT that is conversant with traditional operant behaviorism in that clients are taught to develop a functional analysis of their own upset emotional experience. Specifically, in the early stages of treatment, clients are instructed to identify (a)ctivating events, (b)eliefs, and (c)onsequences that surround individual events resulting in distress. After repeated practice and feedback from the therapist, clients are expected to articulate these sequences readily. Following this, clients are taught to extend this A-B-C analysis to include (D)isputation and (E)ffects of the outcome. This full sequence is then understood as a method of alleviating distress when applied repeatedly. As a means for galvanizing these effects, a number of behavioral activities are typically arranged that allow for in vivo challenge of irrational beliefs. For example, shame attacks are where one seeks out a situation in which the irrational belief may be directly challenged (such as announcing the time in a crowded restaurant to challenge beliefs associated with embarrassment). Another method is referred to as the rational barb, where the therapist states the irrational belief out loud to the client, and the client must rapidly arrive at a disputation (such as comments about physical appearance). Finally, rational role reversal is where the therapist enacts the role of client, and the client must identify irrational beliefs and suggest methods for disputation. These procedures are described in detail in the work of Walen, DiGuiseppe, and Dryden.
It appears from the description offered here that CT and REBT have substantial overlap in conceptualization. Both involve homework designed to identify dysfunctional thinking patterns. Each is highly structured. Each approach emphasizes demonstration of the effects of in session disputation by in vivo application. However, there are some subtle differences. The first is that REBT is more reliant on specific exercises that have been packaged for challenging irrational ideas as they arise. The second is that, despite the broad similarities, most treatment trials have adhered to the format outlined by Beck, resulting in greater empirical support. Indeed, Beck has placed greater emphasis on empirical research, while frankly acknowledging similarities with
Ellis's approach. Finally, REBT emphasizes identification of particular words and styles of describing the world that may result in emotional distress. For example, Ellis has popularized some catch phrases that are liberally applied to challenge the use of particular words to describe personal emotional functioning. Ellis has suggested that people "awful-ize" to refer to the use of something being awful (rather than merely unfortunate or inconvenient). Other words specifically targeted as part of treatment are "should," "ought," and "must." Further, Ellis has encouraged people to try applying the E-prime philosophy, which specifically suggests that people avoid using the verb "to be" as it contributes to broad labeling that fosters an inability to effectively and flexibly challenge disruptive thinking patterns. In 1973 Ellis emphasizes that REBT arises from the philosophical tenets of Epictetus whereby the labeling of something as "good" or "bad" is what makes it so, and that no event is inherently good or bad.
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