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Chapter: Psychology: Treatment of Mental Disorders

Psychological Treatments: Cognitive-Behavioral Approaches

In its early versions, behavior therapy focused on overt behaviors and regarded a per-son’s inner thoughts and feelings as unimportant, and, in any case, not something that could be studied or influenced directly.

Cognitive-Behavioral Approaches


In its early versions, behavior therapy focused on overt behaviors and regarded a per-son’s inner thoughts and feelings as unimportant, and, in any case, not something that could be studied or influenced directly. Several decades ago, however, behavior therapists started to broaden their view, realizing both that thoughts and perceptions do matter and that some of the techniques they had already developed could be applied to these mental events in much the same way they are applied to behaviors. This is obvious in the case of modeling, for example, in which the target for change is often how someone thinks or feels. However, the same is true for operant techniques, which also can be used to encourage more positive self-evaluations and various adap-tive strategies.


In the 1950s, Albert Ellis began to focus on the role cognitions play in causing psy-chological difficulties (Ellis, 1962). He expounded an approach that is now known as rational emotive behavioral therapy. In Ellis’s view, people typically believe that thethings that happen to them (such as being ignored at a party by a roommate) directly lead them to feel or behave in certain ways (such as feeling angry). One way of putting this idea is that people believe that an activating event, which we can call A, leads to a consequence, which we can call C.


Ellis made the point that if this were true—that A directly caused C—then everyone should respond the same way to activating event A each time A occurs. It’s obvious, however, that neither of these things is true. Why not? According to Ellis, what people fail to notice is the hidden element tucked between the A and the C, namely, a belief, or B. That is, Ellis argued that the A never has the power to cause us to feel or behave unless there’s also a belief that translates A into C, leading to an A → B → C sequence. Different people can react to A in different ways because they have their own distinct beliefs. Individuals’ beliefs can also change, leading to new consequences the next time they encounter the activating event.


Ellis claimed that these beliefs, linking activating events to consequences, are often the cause of the problems that lead people to seek therapy. In particular, Ellis suggestedthat some people have highly irrational beliefs, such as “Everything I do must be per-fect” or “I must be in complete control at all times.” Ellis viewed these beliefs as the source of a person’s problems and targeted them with his clinical intervention.


To the A → B → C sequence Ellis added D (disputing the irrational beliefs) and E (substituting more effective beliefs). Ellis sought to effect change in a direct fashion—by means of argument and instruction. He would explicitly discuss and liter-ally dispute (D) the patient’s beliefs and would offer specific—and more effective (E)— substitutes. His manner was teacherlike, and he frequently lectured his patients and exhorted them to modify their irrational ideas about themselves and the world.


In a similar vein, Aaron Beck—who was initially trained as a psychoanalyst— developed cognitive therapy (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). Beck’s core insight—like Ellis’s—is that dysfunctional cognitions play a key role in the development of mental disorders. For example, Beck held that depressed people have negative beliefs about themselves (“I am unlovable”), the world (“It’s a cruel world out there”), and the future (“Things are only going to get worse”). These beliefs are supported by distorted thought processes, such as all-or-nothing thinking (“Now that I’ve lost the election, I’m worthless”), overgeneralization (“I lost my car keys—that’s just like me, I lose every-thing!”), disqualifying the positive (“My doing well on the test today was just a fluke”), and emotional reasoning (“I feel it, therefore I know it’s true”) (Burns, 1980).


To challenge these thought processes, Beck used cognitive restructuring, a set of techniques for changing a person’s beliefs or habits of interpreting the world. These techniques include outright persuasion and, in some cases, confronting the patient with her maladaptive beliefs. In other cases, patients are taught strategies for keeping certain thoughts readily available, to be applied instead of more destructive or distress-ing interpretations of life’s events. In short, there is no single list of techniques that are used in cognitive therapy, but the effort is always toward changing both a person’s behaviors and how she thinks about the world.


To get a feel for how Beck interacts with his patients, consider the following interview with a 26-year-old graduate student who sought treatment for depression:


PATIENT: I agree with the descriptions of me, but I guess I don’t agree that the way I think makes me depressed.


BECK: How do you understand it?


PATIENT: I get depressed when things go wrong. Like when I fail a test.


BECK: How can failing a test make you depressed?


PATIENT: Well, if I fail I’ll never get into law school.


BECK: So failing the test means a lot to you. But if failing a test could drive people into clinical depression, wouldn’t you expect everyone who failed the test to have a depression? . . . Did everyone who failed get depressed enough to require treatment?

PATIENT: No, but it depends on how important the test was to the person.


BECK: Right, and who decides the importance?




BECK: And so, what we have to examine is your way of viewing the test (or the way that you think about the test) and how it affects your chances of getting into law school. Do you agree?




BECK: Do you agree that the way you interpret the results of the test will affect you? You might feel depressed, you might have trouble sleeping, not feel like eating, and you might even wonder if you should drop out of the course.

PATIENT: I have been thinking that I wasn’t going to make it. Yes, I agree.

BECK: Now what did failing mean?


PATIENT: (tearful) That I couldn’t get into law school.


BECK: And what does that mean to you?


PATIENT: That I’m just not smart enough.


BECK: Anything else?


PATIENT: That I can never be happy.


BECK: And how do these thoughts make you feel?


PATIENT: Very unhappy.


BECK: So it is the meaning of failing a test that makes you very unhappy. In fact, believ-ing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by definition, failure to get into law school equals “I can never be happy.” (Beck, Rush, Shaw, & Emery, 1979, 145–146)


Beck’s therapy was initially developed to treat depression (Beck, Rush, Shaw, & Emery, 1979). This makes sense because—as discussed—major depres-sion seems to involve a set of cognitive problems linked to how a person perceives her-self and her world: She believes that she is worthless, and her future is bleak. If bad things occur in her life, they are her fault, and they indicate widespread patterns of upcoming difficulties.


There is room for debate over whether these beliefs produced the depression in the first place, but there is no question that they foster and sustain the depression—and so, to help the patient, it is important to work toward changing the beliefs. However, Beck’s cognitive therapy has also been successfully applied to disorders in which the role of maladaptive beliefs may be less prominent. These include bipolar disorder (Miklowitz & Johnson, 2006), a range of anxiety disorders (Hollon, Stewart, & Strunk, 2006), schizophrenia (Hogarty et al., 2004), obesity (Cooper & Fairburn, 2001), personality disorders (Beck, Freeman, Davis, & Associates, 2004), and chronic pain (Hollon & Beck, 2004).


Although Ellis and Beck both drew attention to the cognitive aspects of mental disorders, they and their followers skillfully blended together cognitive and behavioral techniques. This hybrid or cognitive-behavioral approach is now far more common than “pure” behavioral or “pure” cognitive therapy. There are many variants of cognitive-behavioral therapy, tailored to specific treatment contexts, but as a general rule cognitive-behavioral therapists are present-focused, and are concerned with iden-tifying and solving problems the patient wishes to address. Therapy sessions are highly structured, and the patient is often expected to do homework, which may consist of practicing new skills or new ways of thinking learned during the therapy sessions.


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