Nature and Relation to Behavior Therapy.

Recent innovations in behavior modification have, for the most part, detoured around the role of cognitive processes in the production and alleviation of symptomatology. Although self-reports of private experiences are not verifiable by other observers, these introspective data provide awealth of testable hypotheses. Repeated correlations of measures of inferred constructs with observable behaviors have yielded consistent findings in the predicted direction. Systematic study of self-reports suggests that an individual’s belief systems, expectancies, and assumptions exert a strong influence on his state of well-being, as well as on his directly observable behavior. Applying a cognitive model, the clinician may usefully construe neurotic behavior in terms of the patient’s idiosyncratic concepts of himself and of his animate and inanimate environment. The individual’s belief systems may be grossly contradictory; i.e., he may simulta- neously attach credence to both realistic and unrealistic conceptualizations of the same event or object. This inconsis- tency in beliefs may explain, for example, why an individual may react with fear to an innocuous situation even though he may concomitantly acknowledge that this fear is unrealistic.

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Cognitive therapy, based on cognitive theory, is designed to modify the individual’s idiosyncratic, maladaptive ideation. The basic cognitive technique consists of delineating the individual’s specific misconceptions, distortions, and maladaptive assumptions, and of testing their validity and reasonableness. By loosening the grip of his perseverative, distorted ideation, the patient is enabled to formulate his

The preparation of this report was supported by a grant from the Marsh Foundation. Reprint requests should be sent to 202 Piersol, Hospital of University of Pennsylvania.

This article is a reprint of a previously published article. For citation purposes, please use the original publication details; Behavior Therapy, 1 (1970), pp 184-200.

DOI of original item: http://dx.doi.org/10.1016/S0005- 7894(70)80030-2.

experiences more realistically. Clinical experience, as well as some experimental studies, indicate that such cognitive restructuring leads to symptom relief.

TWO SYSTEMS OF PSYCHOTHERAPY that have recently gained prominence have been the subject of a rapidly increasing number of clinical and experimental studies. Cognitive therapy,1 the more recent entry into the field of psychotherapy, and behavior therapy already show signs of becoming institutionalized. Although behavior therapy has been publicized in

a large number of articles andmonographs, cognitive therapy has received much less recognition. Despite the fact that behavior therapy is based primarily on learning theory whereas cognitive therapy is rooted more in cognitive theory, the two systems of psychotherapy have much in common. First, in both systems of psychotherapy the

therapeutic interview is more overtly structured and the therapist more active than in other psychotherapies. After the preliminary diagnostic interviews in which a systematic and highly detailed description of the patient’s problems is obtained, both the cognitive and the behavior therapists formulate the patient’s presenting symptoms (in cognitive or behavioral terms, respectively) and design specific sets of operations for the particular problem areas. After mapping out the areas for therapeutic

work, the therapist explicitly coaches the patient regarding the kinds of responses and behaviors that are useful with this particular form of therapy. Detailed instructions are presented to the patient,

1 Ellis (1957) used the label “Rational Therapy” which he later changed to “Rational-Emotive Therapy.”

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777ct : nature and relat ion to behav ior therapy

for example, to stimulate pictorial fantasies (system- atic desensitization) or to facilitate his awareness and recognition of his cognitions (cognitive therapy). The goals of these therapies are circumscribed, in contrast to the evocative therapies whose goals are open ended (Frank, 1961). Second, both the cognitive and behavior therapists

aim their therapeutic techniques at the overt symptom or behavior problem, such as a particular phobia, obsession, or hysterical symptom. However, the target differs somewhat. The cognitive therapist focuses more on the ideational content involved in the symptom, viz., the irrational inferences and premises. The behavior therapist focuses more on the overt behavior, e.g., the maladaptive avoidance responses. Both psychotherapeutic systems concep- tualize symptom formation in termsof constructs that are accessible either to behavioral observation or to introspection, in contrast to psychoanalysis, which views most symptoms as the disguised derivatives of unconscious conflicts. Third, in further contrast to psychoanalytic therapy,

neither cognitive therapy nor behavior therapy draws substantially on recollections or reconstructions of the patient’s childhood experiences and early family relationships. The emphasis on correlating present problems with developmental events, furthermore, is much less prominent than in psychoanalytic psycho- therapy. A fourth point in common between these two

systems is that their theoretical paradigms exclude many traditional psychoanalytic assumptions such as infantile sexuality, fixations, the unconscious, and mechanisms of defense. The behavior and cognitive therapists may devise their therapeutic strategies on the basis of introspective data provided by the patient; however, they generally take the patients’ self-reports at face value2 and do not make the kind of high-level abstractions characteristic of psycho- analytic formulations. Finally, a major assumption of both cognitive

therapy and behavior therapy is that the patient has acquired maladaptive reaction patterns that can be “unlearned” without the absolute requirement that he obtain insight into the origin of the symptom. One of the major assets of behavior therapy has

been the large number of well-designed experiments that support certain of its basic assumptions. Although of more recent vintage, several systematic studies supporting the underpinnings of cognitive

2 Although the patient may not be immediately aware of the content of his maladaptive attitudes and patterns, this concept is not “unconscious” in the psychoanalytic sense and is accessible to the patient’s introspection. Furthermore, unlike many psycho- analytic formulations, the inferences can be tested by currently available research techniques.

therapy have also been reported (Carlson, Travers, & Schwab, 1969; Jones, 1968; Krippner, 1964; Loeb, Beck, Diggory, & Tuthill, 1967; Rimm & Litvak, 1969; Velten, 1968). The few controlled- outcome studies of cognitive therapy (Ellis, 1957; Trexler&Karst, 1969) provide preliminary evidence of the effectiveness of this therapy. There are obvious differences in the techniques

used in behavior therapy and cognitive therapy. In systematic desensitization, for example, the behavior therapist induces a predetermined sequence of picto- rial images alternatingwith periods of relaxation. The cognitive therapist, on the other hand, relies more on the patient’s spontaneously experienced and reported thoughts. These cognitions, whether in pictorial or verbal form, are the target for therapeutic work. The technical distinctions between the two systems of psychotherapy are often blurred, however. For example, the cognitive therapist uses induced images to clarify problems (Beck, 1967; 1970), and the behavior therapist uses verbal techniques such as “thought-stoppage” (Wolpe & Lazarus, 1966). The most striking theoretical difference between

cognitive and behavior therapy lies in the concepts used to explain the dissolution of maladaptive responses through therapy. Wolpe, for example, utilizes behavioral or neurophysiological explanations such as counterconditioning or reciprocal inhibition; the cognitivists postulate the modification of con- ceptual systems, i.e., changes in attitudes ormodes of thinking. As will be discussed later, many behavior therapists implicitly or explicitly recognize the importance of cognitive factors in therapy, although they donot expandon these in detail (Davison, 1968; Lazarus, 1968).

Techniques of Cognitive Therapy Cognitive therapy may be defined in two ways: In a broad sense, any technique whose major mode of action is the modification of faulty patterns of thinking can be regarded as cognitive therapy. This definition embraces all therapeutic operations that indirectly affect the cognitive patterns, as well as those that directly affect them (Frank, 1961). An individual’s distorted views of himself and his world, for example, may be corrected through insight into the historical antecedents of his misinterpretations (as in dynamic psychotherapy), through greater congruence between the concept of the self and the ideal (as in Rogerian therapy), and through increas- ingly sharp recognition of the unreality of fears (as in systematic desensitization). However, cognitive therapy may be defined

more narrowly as a set of operations focused on a patient’s cognitions (verbal or pictorial) and on the premises, assumptions, and attitudes underlying

Nature and Relation to Behavior Therapy.

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these cognitions. This section will describe the specific techniques of cognitive therapy.

Recognizing Idiosyncratic Cognitions One of the main cognitive techniques consists of training the patient to recognize his idiosyncratic cognitions or “automatic thoughts” (beck, 1963). ellis (1962) refers to these cognitions as “internalized statements” or “self-statements,” and explains them to the patient as “things that you tell yourself.” these cognitions are termed idiosyncratic because they reflect a faulty appraisal, ranging from a mild distortion to a complete misinterpretation, and because they fall into a pattern that is peculiar to a given individual or to a particular psychopathological state. In the acutely disturbed patient, the distorted

ideation is frequently in the center of the patient’s phenomenal field. In such cases, the patient is very much aware of these idiosyncratic thoughts and can easily describe them. The acutely paranoid patient, for instance, is bombarded with thoughts relevant to his being persecuted, abused, or discriminated against by other people. In the mild or moderate neurotic, the distorted ideas are generally at the periphery of awareness.3 It is therefore necessary to motivate and to train the patient to attend to these thoughts. Manypatients reporting unpleasant affects describe