Cognitive-Behavioral Therapy

   (CBT)

   Behavioral techniques concern activities that may be modified by reflex action without much cogitation on the part of the subject. As "operant conditioning" was conceived by Burrhus Frederick Skinner (1904–1990)—notably in his book Science and Human Behavior (1953)—actions lead either to a reward or to the prevention of a painful stimulus, thus changing behavior by reinforcement or discouragement ("extinction"). Cognitive techniques address such intellectual functions as the reality testing of "automatic thoughts" and involve more the kind of rational persuasion that Paul Dubois conceived (see Psychotherapy: Dubois’s "rational psychotherapy" [1904]). CBT thus draws on two sources: a rich tradition of behavioral therapy going back to Ivan Petrovich Pavlov (1849–1936) and the Russian school of physiologists (that will not be further considered in this Dictionary; however, see Eysenck, Hans Jürgen); it draws as well on more recent efforts to identify errors in cognition as the root problem in such illnesses as depression.

   This more recent tradition begins with the South African psychiatrist Joseph Wolpe (1915–), a lecturer at the University of Witwatersrand, who in 1954 in the AMA Archives of Neurology and Psychiatry described "reciprocal inhibition" as the basis of theeffect of psychotherapy (he amplified these ideas in his 1958 book, Psychotherapy by Reciprocal Inhibition): The anxiety response is inhibited if a stimulus the opposite of anxiety is evoked in an anxiety-producing setting. Applying this theory to humans with phobias, he found that prolonged exposure to the feared setting produced "systematic desensitization." Wolpe was very much a behaviorist and attempted, for example, to convert homosexuals into heterosexuals with behavior therapy techniques.

   (See also Homosexuality and Psychiatry on psychoanalytic attempts to effect this kind of "reparative" therapy.) Yet, his work begins the CBT stream. Building on these findings, in 1963 Aaron Beck (1921–), then associate professor of psychiatry at the University of Pennsylvania, argued in the Archives of General Psychiatry that depression arose in part as a result of "cognitive distortions" involving such themes as "low self-evaluation, ideas of self-deprivation, exaggeration of problems and difficulties, self-criticisms and self-commands, and wishes to escape or die" (p. 333). As Beck elaborated his ideas about depression and cognition in his book Depression: Clinical, Experimental and Theoretical Aspects (1967), the triad of cognitive patterns forcing the individual to "view himself, his world, and his future in an idiosyncratic way" were (1) construing experiences negatively, (2) viewing himself negatively, and (3) viewing the future negatively (p. 255). Cognitive, or insight, psychotherapy, said Beck, focused on neutralizing "automatic thoughts, validating basic truths, and using induced fantasies to modify mood." In an article published in Behavior Therapy in 1970, he spelled out the relationship of cognitive therapy to behavior therapy. His seminal book was Cognitive Therapy of Depression (1979). Cognitive therapy was launched in a medical environment still dominated by psychoanalysis. One colleague informed Beck that cognitive therapy was "like treating malaria with an electric fan." Yet, in clinical trials, cognitive therapy demonstrated roughly the same efficacy in nonhospital depression as did psychopharmacology. In 1994, Beck founded in Bala Cynwyd, Pennsylvania, the Beck Institute for Cognitive Therapy and Research to help train therapists.

   Establishing the effectiveness of "exposure" therapy in the treatment of obsessive-compulsive disorder (1973). It was Janet who in Principles of Psychotherapy (La médecine psychologique) in 1923 initially established that continually ordering a patient to repeat a given compulsive action, or exposure, diminished the patient’s need to do so. Calling them "treatments by suggestion," Janet said that the patients "know very well that they are incapable of performing certain acts voluntarily or else that they will retard their execution by a mass of scruples . . . and they themselves desire to be made to execute certain acts in a forced or automatic way. ‘Have you absolutely decided to feed me with the tube if I do not eat?’ ‘Exactly.’ ‘In that case I am forced and it is you who take the responsibility; I prefer that.’ And she eats as she should" (Eng. Trans., p. 198). Yet the observation was not taken up. In 1973, psychiatrist Isaac M. Marks (1935–) at the Institute of Psychiatry of the Maudsley Hospital in London determined that "exposure in vivo," continuously subjecting patients who had rituals and phobias to a stimulus that evokes their symptoms, produced a lasting diminution of the symptoms themselves. He published the exposure principle first in 1973 in the Canadian Psychiatric Association Journal, advocating "continued exposure to the phobic situation until anxiety and avoidance responses are extinguished" (p. 11). Eight years later, in 1981, he wrote in an article in the American Journal of Psychiatry that on the basis of controlled studies, self-exposure was at least as effective as therapist-accompanied exposure: "For a ritualizer the evoking stimulus might be the discomfort brought on by the perception of dirt, disarray, or uncertainty. Such a stimulus evokes the response of compulsive washing, tidying up, or checking. . . . The compulsive tidier . . . might be asked to untidy his or her possessions. . . . In time, the resultant evoking stimulus of discomfort will be tolerated without evoking rituals or avoidance" (p. 585).