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COGNITIVE BEHAVIORAL THERAPY:MODELING, RATIONAL RESTRUCTURING

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Clinical Psychology­ (PSY401)
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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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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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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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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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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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Table of Contents:
  1. MENTAL HEALTH TODAY: A QUICK LOOK OF THE PICTURE:PARA-PROFESSIONALS
  2. THE SKILLS & ACTIVITIES OF A CLINICAL PSYCHOLOGIST:THE INTERNSHIP
  3. HOW A CLINICAL PSYCHOLOGIST THINKS:Brian’s Case; an example, PREDICTION
  4. HISTORICAL OVERVIEW OF CLINICAL PSYCHOLOGY:THE GREEK PERIOD
  5. HISTORY OF CLINICAL PSYCHOLOGY:Research, Assessment, CONCLUSION
  6. HOW CLINICAL PSYCHOLOGISTS BECAME INVOLVED IN TREATMENT
  7. MODELS OF TRAINING IN CLINICAL PSYCHOLOGY:PROFESSIONAL SCHOOLS
  8. CURRENT ISSUES IN CLINICAL PSYCHOLOGY:CERTIFICATION, LICENSING
  9. ETHICAL STANDARDS FOR CLINICAL PSYCHOLOGISTS:PREAMBLE
  10. THE ROLE OF RESEARCH IN CLINICAL PSYCHOLOGY:LIMITATION
  11. THE RESEARCH PROCESS:GENERATING HYPOTHESES, RESEARCH METHODS
  12. THE CONCEPT OF ABNORMAL BEHAVIOR & MENTAL ILLNESS
  13. CAUSES OF MENTAL ILLNESOVERVIEW OF ETIOLOGY:PANDAS
  14. THE PROCESS OF DIAGNOSIS:ADVANTAGES OF DIAGNOSIS, DESCRIPTION
  15. THE CONCEPT OF PSYCHOLOGICAL ASSESSMENT IN CLINICAL PSYCHOLOGY
  16. THE CLINICAL INTERVIEW:The intake / admission interview, Structured interview
  17. THE ASSESSMENT OF INTELLIGENCE:RELIABILTY AND VALIDITY, CATTELL’S THEORY
  18. INTELLIGENCE TESTS:PURPOSE, COMMON PROCEDURES, PURPOSE
  19. THE USE AND ABUSE OF PSYCHOLOGICAL TESTING:PERSONALITY
  20. THE PROJECTIVE PERSONALITY TESTS:THE RORSCHACH
  21. THE OBSERVATIONAL ASSESSMENT AND ITS TYPES:Home Observation
  22. THE BEHAVIORAL ASSESSMENT THROUGH INTERVIEWS, INVENTORIES AND CHECK LISTS
  23. THE PROCESS AND ACCURACY OF CLINICAL JUDGEMENT:Comparison Studies
  24. METHODS OF IMPROVING INTERPRETATION AND JUDGMENT
  25. PSYCHOLOGICAL INTERVENTIONS AND THEIR GOALS:THE EXPERT ROLE
  26. IMPORTANCE OF PSYCHOTHERAPY:ETHICAL CONSIDERATIONS
  27. COURSE OF NEW CLINICAL INTERVENTIONS:IMPLEMENTING TREATMENT
  28. NATURE OF SPECIFIC THERAPEUTIC VARIABLES:CLIENT’S MOTIVATION
  29. THE BEGINNING OF PSYCHOANALYSIS:THE CASE OF ANNA, THE INSTINCTS
  30. PSYCHOANALYTIC ALTERNATIVES:EGO ANALYSIS, CURATIVE FACTORS
  31. CLIENT CENTERED THERAPY:PURPOSE, BACKGROUND, PROCESS
  32. GESTALT THERAPY METHODS AND PROCEDURES:SELF-DIALOGUE
  33. ORIGINS AND TRADITIONAL TECHNIQUES OF BEHAVIOR THERAPY
  34. COGNITIVE BEHAVIORAL THERAPY:MODELING, RATIONAL RESTRUCTURING
  35. GROUP THERAPY: METHODS AND PROCEDURES:CURATIVE FACTORS
  36. FAMILY AND COUPLES THERAPY:POSSIBLE RISKS
  37. INTRODUCTION AND HISTORY OF COMMUNITY PSYCHOLOGY:THE ENVIRONMENT
  38. METHODS OF INTERVENTION AND CHANGE IN COMMUNITY PSYCHOLOGY
  39. INTRODUCTION AND HISTORY OF HEALTH PSYCHOLOGY
  40. APPLICATIONS OF HEALTH PSYCHOLOGY:OBESITY, HEALTH CARE TRENDS
  41. NEUROPSYCHOLOGY PERSPECTIVES AND HISTORY:STRUCTURE AND FUNCTION
  42. METHODS OF NEUROLOGICAL ASSESSMENT:Level Of Performance, Pattern Analysis
  43. FORENSIC PSYCHOLOGY:Qualification, Testifying, Cross Examination, Criminal Cases
  44. PEDIATRIC AND CHILD PSYCHOLOGY: HISTORY AND PERSPECTIVE
  45. INTERVENTIONS & TRAINING IN PEDIATRIC AND CLINICAL CHILD PSYCHOLOGY