#1970_TC Nature and Relation to Behavior Therapy

7/29/2019 #1970_TC Nature and Relation to Behavior Therapy

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B EHAVIOR THER APY (1970 ) 1 , 18 4-2 00

C o g n i t i v e T h e r a p y : N a t u r e a n dR e la tion t o B e ha v io r T he r a py 1

A A R O N T . B E C KUniversity of Pennsylvania

R e c e n t i n n o v a t i o n s i n b e h a v i o r m o d i f ic a t io n h a v e , f o r t h e m o s t p a r t , d e t o u r e da r o u n d t h e r o l e o f c o g n i t i v e p r o c e s s e s i n t h e p r o d u c t i o n a n d a l le v i a ti o n o f s y m p -t o m a t o l o g y . A l t h o u g h s e l f- r e p o r ts o f p r i v a t e e x p e r i e n c e s a r e n o t v e r i f i ab l e b y o t h e ro b s e r v e r s , t h e s e i n t r o s p e c t i v e d a t a p r o v i d e a w e a l t h o f t e s t a b l e h y p o t h e s e s .R e p e a t e d c o r r e l a t io n s o f m e a s u r e s o f i n f e r r e d c o n s t r u c t s w i t h o b s e r v a b l e b e h a v -i o r s h a v e y i e l d e d c o n s i s t e n t f i n d i n g s i n t h e p r e d i c t e d d i r e c t i o n .S y s t e m a t i c s t u d y o f s e l f - r e p o r t s s u g g e s t s t h a t a n i n d i v i d u a l ' s b e l i e f s y s t e m s ,e x p e c t a n c i e s , a n d a s s u m p t i o n s e x e r t a s t r o n g i n f l u e n c e o n h i s s t a t e o f w e l l - b e i n g , a sw e l l a s o n h i s d i r e c t l y o b s e r v a b l e b e h a v i o r . A p p l y i n g a c o g n i t i v e m o d e l , t h e c l i n i -c i a n m a y u s e f u l l y c o n s t r u e n e u r o t i c b e h a v i o r in t e r m s o f t h e p a t i e n t ' s i d i o s y n c r a t icc o n c e p t s o f h i m s e l f a n d o f h i s a n i m a t e a n d i n a n i m a t e e n v i r o n m e n t . T h e i n d i v i d u a l 'sb e l i e f s y s t e m s m a y b e g r o s s l y c o n t r a d i c t o r y ; i . e. , h e m a y s i m u l t a n e o u s l y a t t a c hc r e d e n c e t o b o t h r e a li s t ic a n d u n r e a l i s ti c c o n c e p t u a l i z a t io n s o f t h e s a m e e v e n t o ro b j e c t . T h i s i n c o n s i s t e n c y i n b e li e f s m a y e x p l a i n , fo r e x a m p l e , w h y a n i n d i v id u a lm a y r e a c t w i t h f e a r to a n i n n o c u o u s s i t u at i o n e v e n t h o u g h h e m a y c o n c o m i t a n t l ya c k n o w l e d g e t h a t t h i s f e a r i s u n r e a l i s t i c .

C o g n i t i v e t h e r a p y , b a s e d o n c o g n i t i v e t h e o r y , i s d e s ig n e d t o m o d i f y t h e i n d i v id u -a l ' s i d i o s y n c r a t i c , m a l a d a p t i v e i d e a t i o n . T h e b a s i c c o g n i t i v e t e c h n i q u e c o n s i s t s o fd e l i n e a t i n g t h e i n d i v i d u a l ' s sp e c i f ic m i s c o n c e p t i o n s , d i s t o r t i o n s , a n d m a l a d a p t i v ea s s u m p t i o n s , a n d o f t e s t i n g t h e i r v a l id i t y a n d r e a s o n a b l e n e s s . B y l o o s e n i n g t h e g r ipo f h i s p e r s e v e r a t i v e , d i s t o r t e d i d e a t i o n , t h e p a t i e n t i s e n a b l e d t o f o r m u l a t e h i s e x p e -r i e n c e s m o r e r e a l i st i c a l ly . C l i n i c a l e x p e r i e n c e , a s w e l l a s s o m e e x p e r i m e n t a ls t u d i e s , i n d i c a t e t h a t s u c h c o g n i t i v e r e s t r u c t u r i n g l e a d s t o s y m p t o m r e l ie f .

Two systems of psychotherapy that have recently gained prominencehave been the subject of a rapidly increasing number of clinical and exper-imental studies. Cognitive therapy, ~ the more recent entry into the field ofpsychotherapy, and behavior therapy already show signs of becominginstitutionalized.Although behavior therapy has been publicized in a large number of

I T h e p r e p a r a t i o n o f t h i s r e p o r t w a s s u p p o r t e d b y a g r a n t f r o m t h e M a r s h F o u n d a t i o n .R e p r i n t r e q u e s t s s h o u l d b e s e n t t o 2 0 2 P i e r so l , H o s p i t a l o f U n i v e r s i t y o f P e n n s y l v a n i a .

E l li s ( 1 9 5 7 ) u s e d t h e l a b e l " R a t i o n a l T h e r a p y " w h i c h h e l a t e r c h a n g e d t o " R a t i o n a l -E m o t i v e T h e r a p y . "

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COGNITIVE AND BEHAVIOR THERAPY 185

a r ti c le s a n d m o n o g r a p h s , c o g n i t i v e t h e r a p y h a s r e c e i v e d m u c h le s s r e c o g -n it io n . D e s p i t e t h e f a c t t h a t b e h a v i o r t h e r a p y i s b a s e d p r i m a r i l y o n l e a r n -in g t h e o r y w h e r e a s c o g n i t i v e t h e r a p y i s r o o t e d m o r e i n c o g n i t i v e t h e o r y ,th e t w o s y s t e m s o f p s y c h o t h e r a p y h a v e m u c h i n co m m o n .

F i r st , in b o t h s y s t e m s o f p s y c h o t h e r a p y t h e t h e r a p e u t i c i n t e r v i e w i sm o r e o v e r t l y s t r u c t u r e d a n d t h e t h e r a p i s t m o r e a c t i v e t h a n i n o t h e r p s y -c h o t h e r a p i e s . A f t e r th e p r e l i m i n a r y d i a g n o s t i c i n t e r v i e w s i n w h i c h a s y s -t e m a t i c a n d h ig h l y d e t a i le d d e s c r i p t i o n o f t h e p a t i e n t ' s p r o b l e m s i so b t a i n e d , b o t h t h e c o g n i t i v e a n d t h e b e h a v i o r t h e r a p i s t s f o r m u l a t e t h ep a t i e n t ' s p r e s e n t i n g s y m p t o m s ( i n c o g n i t i v e o r b e h a v i o r a l t e r m s , r e s p e c -t iv e l y ) a n d d e s i g n s p e c i f i c s e t s o f o p e r a t i o n s f o r t h e p a r t i c u l a r p r o b l e mareas .

A f t e r m a p p i n g o u t t h e a r e a s f o r t h e r a p e u t i c w o r k , t h e t h e r a p i s te x p l ic i tl y c o a c h e s t h e p a t i e n t r e g a r d i n g t h e k i n d s o f r e s p o n s e s a n d b e h a v -i or s t h a t a r e u s e f u l w i t h th i s p a r t ic u l a r f o r m o f t h e r a p y . D e t a i l e d i n s t r u c -t io n s a r e p r e s e n t e d t o t h e p a t i e n t , f o r e x a m p l e , t o s t i m u l a t e p i c t o ri a l f a n -t a s ie s ( s y s t e m a t i c d e s e n s i t i z a t io n ) o r to f a c i li t a te h i s a w a r e n e s s a n dr e c o g n i t io n o f h i s c o g n i t io n s ( c o g n i t iv e t h e r a p y ) . T h e g o a l s o f t h e s et h e r a p i e s a r e c i r c u m s c r i b e d , i n c o n t r a s t t o t h e e v o c a t i v e t h e r a p i e s w h o s eg o a l s a r e o p e n e n d e d ( F r a n k , 1 9 6 1) .

S e c o n d , b o t h t h e c o g n i t i v e a n d b e h a v i o r t h e r a p i s t s a i m th e i r th e r a p e u -t ic t e c h n i q u e s a t t h e o v e r t s y m p t o m o r b e h a v i o r p r o b l e m , s u c h a s a p a r t ic -u l ar p h o b i a , o b s e s s i o n , o r h y s t e ri c a l s y m p t o m . H o w e v e r , t h e ta r g e td i ff e rs s o m e w h a t . T h e c o g n i t i v e t h e r a p i s t f o c u s e s m o r e o n t h e i d e a t io n a lc o n t e n t i n v o l v e d i n t h e s y m p t o m , v i z . , t h e i r r a t i o n a l i n f e r e n c e s a n dp r e m i s e s . T h e b e h a v i o r t h e r a p i s t f o c u s e s m o r e o n t h e o v e r t b e h a v i o r ,e .g ., t h e m a l a d a p t i v e a v o i d a n c e r e s p o n s e s . B o t h p s y c h o t h e r a p e u t i cs y s t e m s c o n c e p t u a l iz e s y m p t o m f o r m a t i o n in t e r m s o f c o n s t r u c t s t h at a r ea c c e s s i b l e e i t h e r t o b e h a v i o r a l o b s e r v a t i o n o r to i n t r o s p e c t i o n , i n c o n t r a s tt o p s y c h o a n a l y s i s , w h i c h v i e w s m o s t s y m p t o m s a s t h e d i s g u i s e d d e r i v a -t i v e s o f u n c o n s c i o u s c o n f li c ts .

T h i r d , i n f u r t h e r c o n t r a s t t o p s y c h o a n a l y t i c t h e r a p y , n e i t h e r c o g n i t i v et h e r a p y n o r b e h a v i o r t h e r a p y d r a w s s u b s t a n ti a ll y o n r e c o l l e c ti o n s o rr e c o n s t r u c ti o n s o f th e p a t i e n t 's c h i l d h o o d e x p e r i e n c e s a n d e a r l y f a m i lyr e l a t i o n s h i p s . T h e e m p h a s i s o n c o r r e l a t i n g p r e s e n t p r o b l e m s w i t h d e v e l -o p m e n t a l e v e n t s , f u r th e r m o r e , i s m u c h l e s s p r o m i n e n t t h a n i n p s y c h o -a n a ly t ic p s y c h o t h e r a p y .

A f o u r t h p o i n t in c o m m o n b e t w e e n t h e s e t w o s y s t e m s is th a t t h e i r t h e o -r e t i c a l p a r a d i g m s e x c l u d e m a n y t r a d i t i o n a l p s y c h o a n a l y t i c a s s u m p t i o n ss u c h a s in f a n ti le s e x u a l i t y , f i x a ti o n s , t h e u n c o n s c i o u s , a n d m e c h a n i s m s o fd e f e n s e . T h e b e h a v i o r a n d c o g n i t i v e t h e r a p i s t s m a y d e v i s e t h e i r t h e r -


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186 AARON T. BECKa p e u t i c s t r a te g i e s o n t h e b a s i s o f i n t r o s p e c t i v e d a t a p r o v i d e d b y th ep a t i e n t ; h o w e v e r , t h e y g e n e r a l l y t a k e t h e p a t i e n t s ' s e l f - r e p o r t s a t f a c ev a l u e 3 a n d d o n o t m a k e t h e k i n d o f h i g h -l e v e l a b s t r a c t i o n s c h a r a c t e r i s ti co f p s y c h o a n a l y t i c f o r m u l at io n s .

F i n a ll y , a m a j o r a s s u m p t i o n o f b o t h c o g n i t i v e th e r a p y a n d b e h a v i o rt h e r a p y i s t h a t th e p a t i e n t h a s a c q u i r e d m a l a d a p t i v e r e a c t i o n p a t t e r n s t h a tc a n b e " u n l e a r n e d " w i t h o u t t h e a b s o l u t e r e q u i r e m e n t t h a t h e o b t a i ni n si g h t i n to t h e o r ig i n o f th e s y m p t o m .

O n e o f t h e m a j o r a s s e t s o f b e h a v i o r t h e r a p y h a s b e e n t h e l ar g e n u m b e ro f w e l l - d e s i g n e d e x p e r i m e n t s t h a t s u p p o r t c e r t a i n o f it s b a s i c a s s u m p -t io n s . A l t h o u g h o f m o r e r e c e n t v i n t a g e , s e v e r a l s y s t e m a t i c s t u d i e s s u p -p o r t i n g th e u n d e r p in n i n g s o f c o g n i t i v e t h e r a p y h a v e a l s o b e e n r e p o r t e d( C a r l s o n , T r a v e r s , & S c h w a b , 1 9 6 9 ; J o n e s , 1 9 6 8 ; K r i p p n e r , 1 9 6 4 ; L o e b ,B e c k , D i g g o r y , & T u t h i ll , 1 9 6 7 ; R i m m & L i t v a k , 1 9 6 9 ; V e l t e n , 1 9 6 8) .T h e f e w c o n t r o l l e d - o u t c o m e s t u d i e s o f c o g n i t i v e t h e r a p y ( E l li s, 1 9 5 7 ;T r e x l e r & K a r s t , 1 9 6 9 ) p r o v i d e p r e l im i n a r y e v i d e n c e o f t h e e f f e c t i v e n e s so f t h is t h e r a p y .

T h e r e a r e o b v i o u s d i f fe r e n c e s in th e t e c h n i q u e s u s e d i n b e h a v i o rt h e r a p y a n d c o g n i t i v e t h e r a p y . I n s y s t e m a t i c d e s e n s i t iz a t i o n , f o r e x a m p l e ,t h e b e h a v i o r t h e r a p is t i n d u c e s a p r e d e t e r m i n e d s e q u e n c e o f p ic t or ia li m a g e s a l te r n a t in g w i t h p e r i o d s o f re l a x a t io n . T h e c o g n i t i v e t h e r a p i s t , o nt h e o t h e r h a n d , r e l i e s m o r e o n t h e p a t i e n t ' s s p o n t a n e o u s l y e x p e r i e n c e da n d r e p o r t e d t h o u g h t s . T h e s e c o g n i t i o n s , w h e t h e r i n p i c t o r i a l o r v e r b a lf o r m , a r e t h e t a r g e t fo r t h e r a p e u t i c w o r k . T h e t e c h n i c a l d i s t i n c ti o n sb e t w e e n th e t w o s y s t e m s o f p s y c h o t h e r a p y a r e o f t e n b l u r re d , h o w e v e r .F o r e x a m p l e , t h e c o g n i t i v e t h e r a p i s t u s e s i n d u c e d i m a g e s t o c l a r i f yp r o b l e m s ( B e c k , 1 9 6 7 ; 1 9 7 0 ) , a n d t h e b e h a v i o r t h e r a p i s t u s e s v e r b a l t e c h -n i q u e s s u c h a s " t h o u g h t - s t o p p a g e " ( W o l p e & L a z a r u s , 1 9 66 ).

T h e m o s t s t r i k i n g t h e o r e t i c a l d i f f e r e n c e b e t w e e n c o g n i t i v e a n d b e h a v -i o r t h e r a p y l ie s in t h e c o n c e p t s u s e d t o e x p l a i n t h e d i s s o l u t i o n o f m a l a d a p -r iv e r e s p o n s e s t h r o u g h t h e r a p y . W o l p e , f o r e x a m p l e , u t il i z e s b e h a v i o r a l o rn e u r o p h y s i o l o g i c a l e x p l a n a t i o n s s u c h a s c o u n t e r c o n d i t i o n i n g o r r e c i p r o -c a l i n h ib i ti o n ; t h e c o g n i t i v is t s p o s t u l a t e t h e m o d i f ic a t i o n o f c o n c e p t u a ls y s t e m s , i. e. , c h a n g e s i n a t ti t u d e s o r m o d e s o f t h in k i ng . A s w i ll b e d i s-c u s s e d l a te r , m a n y b e h a v i o r t h e r a p i s t s i m p l i ci t ly o r e x p l i c it l y r e c o g n i z et h e i m p o r t a n c e o f c o g n i t i v e f a c t o r s i n t h e r a p y , a l t h o u g h t h e y d o n o te x p a n d o n t h e s e in d e t a il ( D a v i s o n , 1 9 6 8 ; L a z a r u s , 1 9 6 8 ).

Although the patient may not be immediately aware of the content of his maladaptiveattitudes and patterns, this con cept is not " unconsciou s" in the psychoanalytic sense and isaccessible o the patien t's introspection. Furthermo re, unlike ma ny psycho analytic formula-tions, the inferences can be tested b y currently available research techniques.


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COGNITIVE AND BEHAVIOR THERAPY 187TECHNIQUES OF COGNITIVE THERAPY

Cognitive therapy may be defined in two ways: In a broad sense, anytechnique whose major mode of action is the modification of faulty pat-terns of thinking can be regarded as cognitive therapy. This definitionembraces all therapeutic operations that indirectly affect the cognitivepatterns, as well as those that directly affect them (Frank, 1961). An indi-vidual's distorted views of himself and his world, for example, may becorrected through insight into the historical antecedents of his misin-terpretations (as in dynamic psychotherapy), through greater congruencebetween the concep t of the self and the ideal (as in Rogerian therapy), andthrough increasingly sharp recognition of the unreality of fears (as in sys-tematic desensitization).

However, cognitive therapy may be defined more narrowly as a set ofoperations focused on a patient's cognitions (verbal or pictorial) and onthe premises, assumptions, and attitudes underlying these cognitions.This section will describe the specific techniques of cognitive therapy.Recognizing Idiosyncratic C ognitions

One of the main cognitive techniques consists of training the patient torecognize his idiosyncratic cognitions or "automatic thoughts" (Beck,1963). Ellis (1962)refers to these cognitions as "internal ized statements"or "self-stat ements," and explains them to the patient as "things that youtell yourself." These cognitions are termed idiosyncratic because theyreflect a faulty apparisal, ranging from a mild distortion to a completemisinterpretation, and because they fall into a pattern that is peculiar to agiven individual or to a particular psychopathological state.In the acutely disturbed patient, the distorted ideation is frequently inthe center of the patient's phenomenal field. In such cases, the patient isvery much aware of these idiosyncratic thoughts and can easily describethem. The acutely paranoid patient, for instance, is bombarded withthoughts relevant to his being persecuted, abused, or discriminatedagainst by other people. In the mild or moderate neurotic, the distortedideas are generally at the periphery of awareness. 4 It is therefore neces-sary to motivate and to train the patient to attend to these thoughts.Many patients reporting unpleasant affects describe a sequence consist-ing of a specific event (external stimulus) leading to an unpleasant affect.For instance, the patient may outline the sequence of (a) seeing an oldfriend and then (b) experiencing a feeling of sadness. Oftentimes, the

4 In obsessional neurosis,of course, the idiosyncratic deas are central and the patient hasdifficulty n ignoring hem.


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188 AARON T. BECKsadness is inexplicable to the patient. Another person (a) hears aboutsomebody having been killed in an automobile accident and (b) feelsanxiety. However, he cannot make a direct connection between these twophenomena; e.g., there is a missing link in the sequence.

In these instances of a particular event leading to an unpleasant affect,it is possible to discern an intervening variable, namely, a cognition,which forms the bridge between the external stimulus and the subjectivefeeling. Seeing an old friend stimulates cognitions such as "It won't belike old times," or "He won't accept me as he used to." The cognitionthen generates the sadness. The report o f an automobile acc ident stimu-lates a pictorial image in which the patient himself is the victim of anautomobile accident. The image then leads to the anxiety.

This paradigm can be further illustrated by a number of examples. Apatient treated by the writer complained that he experienced anxietywhenever he saw a dog. 5 He was puzzled by the fact that he experiencedanxiety even when the dog was chained or caged or else was obviouslyharmless. The patient was instructed: "N otic e what thoughts go throughyour mind the next time you see a dog--any dog." At the next interview,the patient reported that during numerous encounters with dogs betweenappointments, he had recognized a phenomenon that he had not noticedpreviously; namely, that each time he saw the dog he had a thought suchas "It's going to bite me."

By being able to detect the intervening cognitions, the patient was ableto understand why he felt anxious, namely, he indiscriminately regardedevery dog as dangerous. He stated, "I even got that thought when I saw asmall poodle. Then I realized how ridiculous it was to think tha t a poodlecould hurt me." He also recognized that when he saw a big dog on a leash,he thought of the most deleterious consequences: "Th e dog will jump upand bite out one of my eyes," or "I t will jump up and bite my jugular veinand kill me." Within 2 or 3 weeks, the patient was able to overcome com-pletely his long-standing dog phobia simply by recognizing his cognitionswhen exposed to a dog.Another example was provided by a college student who experiencedinexplicable anxiety in a social situation. After being trained to examineand write down his cognitions, he reported that in social situations hewould have thoughts such as, "Th ey think I look pathetic," or "No bodywill want to talk to me," or "I'm just a misfit." These thoughts werefollowed by anxiety.

s Ellis (1962) described a similar case.


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COGNITIVE AND BEHAVIOR THERAPY 189A patient complained that he was chronically angry at practically ev-erybody whom he saw, but could not account for his angry response to

these people. After some training at recognizing his cognitions, hereported having such thoughts as "H e' s pushing me around ," "He thinksI'm a pushover," "He's trying to take advantage of me." Immediatelyafter experiencing these thoughts, he would feel angry at the individualtowards whom they were directed. He also realized that there was no re-alistic basis for his appraising people in this negative way.

Sometimes, the cognition may take a pictorial form instead of, or inaddition to, the verbal form (Beck, 1970). A woman who experiencedspurts of anxiety when riding across a bridge was able to recognize thatthe anxiety was preceded by a pictorial image of her car breaking throughthe guard rail and falling off the bridge. Another woman, with a fear ofwalking alone, found that her spells of anxiety followed images of herhaving a heart attack and being left helpless and dying on the street. Acollege student discovered that his anxiety at leaving his dormitory atnight was triggered by visual fantasies of being attacked.

The idiosyncratic cognitions (whether pictorial or verbal) are very rapidand often may contain an elaborate idea compressed into a very shortperiod of time, even into a split second. These cognitions are experiencedas though they are automatic; i.e., they seem to arise as if by reflex ratherthan through reasoning or deliberation. They also seem to have an invol-untary quality. A severely anxious or depressed or paranoid person, forexample, may continually experience the idiosyncratic cognitions, eventhough he may try to ward them off. Furthermore, these cognitions tendto appear completely plausible to the patient.Distancing

Even after a patient has learned to identify his idiosyncratic ideas, hemay have difficulty in examining these ideas objectively. The thoughtoften has the same kind of salience as the perception o f an external stimu-lus. "Distancing" refers to the process of gaining objectivity towardsthese cognitions. Since the individual with a neurosis tends to accept thevalidity of his idiosyncratic thoughts without subjecting them to any kindof critical evaluation, it is essential to train him to make a distinctionbetween thought and external reality, between hypothesis and fact.Patients are often surprised to discover that they have been equating aninference with reality and tha t they have attached a high degree of truth-value to their distorted concepts.

The therapeutic dictum communicated to the patient is as follows:


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190 AARON T. BECKSimply because he thinks something does not necessarily mean that it istrue. While such a dictum may seem to be a platitude, the writer has foundwith surprising regularity that patients have benefited from the repeatedreminder that thoughts are not equivalent to external reality.

Once the patient is able to "objectify" his thoughts, he is ready for thelater stages of reality testing: applying rules of evidence and logic andconsidering alternative explanations.Correcting Cognitive Distortions and Deficiencies

The writer has already indicated that patients show faulty or disorderedthinking in certain circumscribed areas of experience. In these particularsectors, they have a reduced ability to make fine discriminations and tendto make global, undifferentiated judgments. Part o f the task of cognitivetherapy is to help the patient to recognize faulty thinking and to make ap-propriate corrections. It is often very useful for the patient to specify thekind of fallacious thinking involved in his cognitive responses.Arbitrary inference refers to the process of drawing a conclusion whenevidence is lacking or is actually contrary to the conclusion. This type ofdeviant thinking usually takes the form of personalization (or self-reference). A depressed patient, who saw a frown on the face of a pas-serby, thought, "He is disgusted with me." A phobic girl of 21, readingabout a woman who had had a heart attack, got the thought, "I probablyhave heart disease." A depressed woman, who was kept waiting for a fewminutes by the therapist, thought, "He has deliberately left in order toavoid seeing me,"Overgeneralization refers to the process of making an unjustified gener-alization on the basis of a single incident. This may take the form that wasdescribed in the case o f the man with the dog phobia, who generalizedfrom a particular dog that might attack him to all dogs. Another exampleis a patient who thinks, "I never succeed at anything" when he has asingle isolated failure.Magnification refers to the propensity to exaggerate the meaning orsignificance of a particular event. A person with a fear of dying, forinstance, interpreted every unpleasant sensation or pain in his body as asign of some fatal disease such as cancer, heart attack, or cerebral hemor-rhage. Ellis (1962) applied the label "castrophizing" to this kind ofreaction.

As noted above, it is often helpful for the patient to label the particularaberration involved in his maladaptive cognition. Once the patient has


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COGNI T I VE AND BE HAVI OR THE RAPY 191firmly established that a particular type of cognition, such as "Tha t dog isgoing to bite me," is invalid, he will be equipped to correc t this cognitionon subsequent occasions. For example, his planned, rational response tothe stimulus of a toy poodle would be, "Actually, it is just a harmlesspoodle and there is only a remote chance that it would bite me. And evenif it did, it could not really injure me."Cognitive deficiency refers to the disregard for an important aspect of alife situation. Patients with this defect ignore, fail to integrate, or do notutilize information derived from experience. Such a patient, conse-quently, behaves as though he has a defect in his system of expectations:He consistently engages in behavior which he realizes, in retrospect, isself-defeating. This class of patients includes those who " ac t out, " e.g.,psychopaths, as well as those whose overt behavior sabotages importantpersonal goals. These individuals sacrifice long-range satisfaction orexpose themselves to later pain or danger in favor of immediate satisfac-tions. This category includes problems such as alcoholism, obesity, drugaddition, sexual deviation, and compulsion gambling.

The deficient-anticipation patients show two major characteristics:First, when they yield to their wishes to engage in self-defeating, danger-ous, or antisocial activities, they are oblivious of the probableconsequences o f their actions. At these times, they avoid thinking aboutthe consequences by concentrating only on the present activity. Theymay fortify this modus operandi through an elaborate system of self-deceptions, such as "I t can't do any harm to cut loose, now." Secondly,irrespective of how often the individual is "burned" as a result of hismaladaptive actions, he does not seem to integrate knowledge of thecause-and-effect relationships into his behavior.

Therapy of such cases consists of training the patient to think of theconsequences as soon as his self-defeating wish arises. Considera tion ofthe long-range loss must be forced into the interval between impulse andaction. A patient, for instance, who continually operated his car beyondthe speed limit or drove through stoplights was surprised each time hewas stopped by a traffic officer. On interview, it was discovered that thepatient was generally absorbed in a fantasy while driving--he imagedhimself as a famous racing-car driver engaged in a race. Therapy at firstconsisted of trying to get him to watch the odometer--but withoutsuccess. The next approach consisted of inducing fantasies of speeding,getting caught, and receiving punishment. At first, the patient had greatdifficulty in visualizing getting caught even though, in general, he couldfantasize almost everything. However, after several sessions of induced


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1 9 2 A A R O N T . B E C K

f a n t a s i e s , h e w a s a b l e t o i n c o r p o r a t e a n e g a t i v e o u t c o m e i n t o h i s f a n t a s y .S u b s e q u e n t l y , h e s t o p p e d d a y d r e a m i n g w h i l e d r i v i n g a n d w a s a b l e t oo b s e r v e t r a f f i c r e g u l a t i o n s .

I n t h e f o l l o w i n g c a s e r e p o r t , s e v e r a l c o g n i t i v e t e c h n i q u e s d i r e c t e d a tm o d i f y i n g a n x i e t y p r o n e n e s s a r e i l l u s t r a t e d .

C A S E R E P O R T ~M r s . G . w a s a n a t t r a c t iv e 2 ? - y e a r - o ld m o t h e r o f t h r e e c h il d r e n . W h e n f ir s t se e n b y t h e

w r i t e r , s h e c o m p l a i n e d o f p e r i o d s o f a n x i e t y l a s t i n g u p t o 6 o r 7 h r a d a y a n d r e c u r r i n gr e p e a t e d ly o v e r a 4 - y e a r p e r io d . S h e h a d c o n s u l t e d h e r f a m i l y p h y s i c ia n , w h o h a d p r e s c r i b e da v a r i e t y o f se d a t i v es , i n c l u di n g T h o r a z i n e , w i t h o u t a n y a p p a r e n t i m p r o v e m e n t .

I n a n a n a l y s is o f t h e c a u s e - a n d -e f f e c t s e q u e n c e o f h e r a n x i e t y , t h e f o l l o w in g f a c ts w e r ee l i ci t e d . T h e f i r s t a n x i e t y e p i s o d e o c c u r r e d a b o u t 2 w e e k s a f t e r s h e h a d h a d a m i s c a r r i a g e .A t t h a t t i m e s h e w a s b e n d i n g o v e r t o b a t h e h e r 1 - y ea r -o l d s o n , a n d s h e s u d d e n l y b e g a n t of e e l f a i n t . F o l l o w i n g t h i s e p i so d e , s h e h a d h e r f i rs t a n x i e t y a t t a c k w h i c h l a s t e d s e v e r a l h o u r s .T h e p a t i e n t c o u l d n o t fi n d a n y e x p l a n a t i o n f o r h e r a n x i e ty . H o w e v e r , w h e n t h e w r i t e r a sk e dw h e t h e r s h e h a d h a d a n y t h o u g h t a t t h e t i m e s h e f el t d i z zy , s h e r e c a ll e d h a v i n g h a d t h et h o u g h t , " S u p p o s e I s h o u l d p a s s o u t a n d i n j u r e t h e b a b y . " I t s e e m e d p l a u s i b le t h a t h e r d i zz i -n e s s , w h i c h w a s p r o b a b l y t h e r e s u l t o f a p o s t p a r t u m a n e m i a , l e d t o t h e f e a r s h e m i g h t f a i n ta n d d r o p t h e b a b y . T h i s f e a r t h e n p r o d u c e d a n x i e t y , w h i c h s h e i n t e r p r e t e d a s a s ig n t h a t s h ew a s " g o i n g to p i e c e s . "

U n t i l t h e t i m e o f h e r m i s c a rr i a g e , th e p a t i e n t h a d b e e n r e a s o n a b l y c a r e f r e e a n d h a d n o t e x -p e r i e n c e d a n y e p i s o d e s o f a n x i e t y . H o w e v e r , a f t e r h e r m i s c a r r ia g e , s h e p e r io d i c a ll y h a d t h et h o u g h t , " B a d t h i n g s c a n h a p p e n to m e . " S u b s e q u e n t l y , w h e n s h e h e a r d o f s o m e b o d y ' sb e c o m i n g s i ck , s h e o f t e n w o u l d h a v e t h e t h o u g h t , " T h i s c a n h a p p e n t o m e , " a n d s h e w o u l db e g i n t o f e e l a n x i o u s .

T h e p a t i e n t w a s i n s t r u c t e d to t r y t o p i n p o i n t a n y t h o u g h t s t h a t p r e c e d e d f u r t h e r e p i s o d e so f a n x i e ty . A t t h e n e x t i n t e r v i e w , s h e r e p o r t e d t h e f o l lo w i n g e v e n t s :1 . O n e e v e n i n g , s h e h e a r d t h a t t h e h u s b a n d o f o n e o f h e r f ri e n d s w a s s i c k w i t h a s e v e r ep u l m o n a r y i n f e ct i on . S h e t h e n h a d a n a n x i e t y a t t a c k l a s t in g s e v e r a l h o u rs . I n a c c o r d a n c ew i t h t h e i n s t r u c t i o n s , s h e t r i e d t o r e c a l l th e p r e c e d i n g c o g n i t i o n , w h i c h w a s , " T o m c o u l d g e ts i ck l i k e t h a t a n d m a y b e d i e . "

2 . S h e h a d c o n s i d e r a b l e a n x i e t y j u s t b e f o r e s t a r t i n g a tr i p t o h e r s i s t e r ' s h o u s e . S h ef o c u s e d o n h e r t h o u g h t s a n d r e a l iz e d s h e h a d t h e r e p e t i t i v e t h o u g h t t h a t s h e m i g h t g e t s i c ko n t h e t r i p . S h e h a d h a d a s e r i o u s e p i s o d e o f g a s t r o e n t e r i t i s d u r i n g a p r e v i o u s t r i p to h e rs i s t e r ' s h o u s e . S h e e v i d e n t l y b e l i e v e d t h a t s u c h a s i c k n e s s c o u l d h a p p e n t o h e r a g a i n .

3 . O n a n o t h e r o c c a s i o n , s h e w a s f ee l in g u n e a s y a n d o b j e c t s s e e m e d s o m e w h a t u n r e a l t oh e r . S h e t h e n h a d t h e t h o u g h t t h a t s h e m i g h t b e lo s in g h e r m i n d a n d i m m e d i a t e l y e x p er i -e n c e d a n a n x i e t y a t t a ck .

4 . O n e o f h e r f r i e n d s w a s c o m m i t t e d t o a s t a t e h o s p i t a l b e c a u s e o f a p s y c h i a t r i c i l l ne s s .T h e p a t i e n t h a d t h e t h o u g h t , " T h i s c o u l d h a p p e n t o m e . I c o u l d l o s e m y m i n d . " W h e n q u e s -t i o n e d a b o u t w h y s h e w a s a f r a i d o f l o s i n g h e r m i n d , s h e s t a t e d t h a t s h e w a s a f r a i d t h a t if s h ew e n t c r a z y , s h e w o u l d d o s o m e t h i n g t h a t w o u l d h a r m e i t h e r h e r c h i l d r e n o r h e rs e lf .

I t w a s e v i d e n t t h a t t h e p a t i e n t ' s c r u c i a l f e a r w a s t h e a n t i c i p a t i o n o f l o s s o f c o n t r o l ,w h e t h e r b y f a i n ti n g o r b y b e c o m i n g p s y c h o t ic . T h e p a t i e n t w a s r e a s s u r e d t h a t t h e r e w e r e n o

6 T h i s p a t i e n t w a s t r e a t e d i n co l l a b o r a t io n w i t h D r . W i l l ia m D y s o n .


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C OGNITIVE AND B EHAVIOR THER APY 193signs that she w as going psychotic. She was also provided with an exp lanation of the arousalof her anxiety and of her secondary elaborat ion o f the m eaning of these at tacks.Th e m ajor therapeutic thrust in this case was coaching the patient to recall and reflect onthe thoughts that preceded her anxiety attacks. The realization that these attacks wereinitiated by a cogn ition rather than by som e vague mysterious force convinced h er she w asneither totally vulnerable nor unable to control her reactions. Furthermo re, by learning topinpoint the anxiety-reducing thoughts, she w as able to gain some detachment and to sub jectthem to reality testing. Co nsequently, she w as able to nullify the effects of those thoughts.Du ring the nex t few week s, her anxiety attacks became less frequent and less intense and,by the end of 4 weeks, they disappeared completely.

D I F F E R E N C E S I N C O N C E P T U A L F R A M E W O R K B E T W E E NB E H A V IO R T H E R A P Y A N D C O G N I T I V E TH E R A P YB e h a v i o r t h e ra p i s ts c o n c e p t u a l i z e d i s o r d e r s o f b e h a v i o r a n d p r o c e -

d u r e s f o r t h e i r a m e l i o r a t i o n w i th i n a t h e o r e t i c a l f r a m e w o r k b o r r o w e df r o m t h e f ie ld o f p s y c h o l o g i c a l l e a r n i n g t h e o r y a n d e s p e c i a l l y b y m e a n s o fc o n c e p t s o f c l a ss i ca l a n d o p e r a n t c o n d i t io n i n g . S i n c e t h e s e c o n c e p t s a r ed e r i v ed m a i n ly f r o m e x p e r i m e n t s w i th a n i m a l s , th e y f o c u s o n t h e o b s e r v a -b le b e h a v i o r o f th e o r g a n i s m . I n fa c t , m o s t o f t h e p u b l i s h e d w r i t i n g s o nb e h a v i o r th e r a p y t e n d t o e s c h e w i n f er r ed o r h y p o t h e s i z e d p s y c h o l o g i c a ls ta t es w h i ch c a n n o t b e d i r ec t ly o b s e r v e d a n d m e a s u r e d . C o n c e p t s a n dp r i n c i p le s b a s e d o n i m m e d i a t e r e f e r e n t s in t h e o r g a n i s m ' s e n v i r o n m e n th a v e a d v a n t a g e s o f p a r s i m o n y , t e s t a b i l it y , q u a n t if i a b i li t y , a n d r e li a b il i ty .H o w e v e r , t h is f r a m e w o r k d o e s n o t r e a d il y a c c o m m o d a t e n o t io n s o f in t er -n a l p s y c h o l o g i c a l s t a t e s s u c h a s t h o u g h t s , a t t i tu d e s , a n d t h e li k e , w h i c hw e c o m m o n l y u s e t o u n d e r s t a n d o u r s e l v e s a n d o t h e r p e o p l e. C o g n i t i v et h e r a p i s t s a r e m o r e w i l l i n g t o u s e t h e s e i n f e r r e d p s y c h o l o g i c a l s t a t e s , c o l -l e c t i v e l y c a l l e d " c o g n i t i o n s , " a s c l in i c a l d a t a . C o n s e q u e n t l y , l a r g e a n du s e f u l s e t s o f v a r i a b le s a r e d i r e c tl y t a k e n i n to a c c o u n t .

I n r e c e n t y e a r s , s e v e r a l w r i t e r s in t h e a r e a o f b e h a v i o r t h e r a p y h a v e a c -k n o w l e d g e d t h e i m p o r t a n c e o f m e d i a t io n a l c o n s t r u c t s o r c o g n i t iv ep r o c e s s e s in b e h a v i o r t h e r a p y ( B r a d y , 1 9 6 7 ; D a v i s o n , 1 9 6 8 ; F o l k i n s ,L a w s o n , O p t o n , & L a z a r u s , 1 9 6 8 ; L a z a r u s , 1 9 6 8 ; L e i t e n b e r g , A g r a s ,B a r l o w , & O l i v e a u , 1 9 6 9 ; L o n d o n , 1 9 6 4 ; M i s c h e l , 1 9 6 8 ; M u r r a y &J a c o b s o n , 1 9 6 9 ; S l o a n e , 1 9 6 9 ; V a l in e & R a y , 1 9 6 7 ; W e i t z m a n , 1 9 6 7) .T h e i r c o g n i t i v e f o r m u l a t i o n s , h o w e v e r , h a v e f o r t h e m o s t p a r t b e e n b r i e f .S u b s t a n t i a l a m p l i f ic a t io n o f th e n a t u r e o f c o g n i t i v e p r o c e s s e s i s n e c e s s a r yt o a c c o u n t a d e q u a t e l y f o r c li n ic a l p h e n o m e n a a n d f o r th e e f f e c t s o f t h e r a -p e u t ic i n t e r v e n t i o n ( s e e W e i t z m a n , 1 9 6 7) .

A g r e a t e r e m p h a s i s o n t h e i n d i v i d u a l 's d e s c r i p t i o n s o f internal e v e n t sc a n l ea d t o a m o r e c o m p l e t e v i ew o f h u m a n p s y c h o p a t h o l o g y a n d t hem e c h a n i s m s o f b e h a v i o r a l c h a n g e . B y u s in g i n t r o s p e c t i v e d a t a , th e c o g n i -


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1 9 4 A A R O N T . B E C K

t i v e t h e o r i s t h a s a c c e s s t o th e p a t i e n t ' s t h o u g h t s , i d e a s , a t t i tu d e s , d r e a m s ,a n d d a y d r e a m s . T h e s e i d e a t i o n a l p r o d u c t i o n s p r o v i d e t h e c o g n i t i v et h e o r i s t w i t h t h e r a w m a t e r i a l s w i t h w h i c h h e c a n f o r m c o n c e p t s a n dm o d e l s . S u c h c o n c e p t s a r e a l s o c a p a b l e o f g e n e ra t in g h y p o t h e s e s a m e n a -b l e t o c o n t r o l l e d e x p e r i m e n t s o n p s y c h i a t r i c p a t i e n ts ( L o e b e t a l . , 1967) .A l s o , i n t r o s p e c t i v e d a t a , s u c h a s d r e a m s a n d c o g n i t i o n s , h a v e b e e na d a p t e d t o s y s t e m a t i c i n v e s t i g a t i o n ( B e c k , 1 9 6 7 ) .S t u d y a n d a n a l y s i s o f t h e i n t r o s p e c t i v e d a t a s u g g e s t t h a t t h e c o g n i t i v eo rgan i za t i on , f a r f r om be ing a mere l i nk i n t he s t imu lus r e sponse cha in , i sa q u a s i - a u t o n o m o u s s y s t e m i n i ts o w n ri gh t . A l t h o u g h t h i s s y s t e m g e n e r -a l ly i n te r a c t s w i t h t h e e n v i r o n m e n t t o a l a r g e e x t e n t , it m a y a t o t h e r t i m e sb e r e l at iv e l y in d e p e n d e n t o f t h e e n v i r o n m e n t ; f o r e x a m p l e , w h e n t h ep a t i e n t is d a y d r e a m i n g o r in th e g r i p o f an a b n o r m a l s t a t e s u c h a s d e p r e s -s ion .B y g e t t i n g i n s i d e t h e p s y c h o l o g i c a l m a t r i x , a s i t w e r e , t h e c o g n i t i v et h e o r i s t g a in s a g li m p s e o f c o n s i d e r a b l e a c t i v it y . I n t r o s p e c t i v e d a t ai n d i c a t e t h e e x i s t e n c e o f c o m p l e x o r g a n i z a t i o n s o f c o g n i t i v e s t r u c t u r e si n v o l v e d in t h e p r o c e s s e s o f s c r e e n i n g e x t e r n a l s t i m u l i, i n t e r p r e ti n g e x p e -r i e n c e s , s t o ri n g a n d s e l e c t i v e l y r e c al li n g m e m o r i e s , a n d s e t ti n g g o a l s a n dp l a n s ( H a r v e y , H u n t & S c h r o d e r , 1 9 6 1) . D a t a s u g g e s t t h a t c o g n i t i v e or -g a n i z a t io n s a r e h ig h l y a c t iv e a n d a r e m u c h m o r e t h a n a s i m p l e c o n d u i tb e t w e e n s t i m u l u s a n d r e s p o n s e .

A COGNITIVE MO DEL OF PSYCHOPATHOLOGYT h e t o t a l c o g n i t i v e o r g a n i z a t i o n a p p e a r s t o b e c o m p o s e d o f p r i m i t iv es y s t e m s c o n s is t i n g o f r e l a t i v e l y c r u d e c o g n i t i v e s tr u c t u r e s ( c o r r e s p o n d i n g

t o F r e u d ' s n o t i o n o f P r i m a r y P r o c e s s ) , an d o f m o r e m a t u r e s y s t e m s c o m -p o s e d o f r e f in e d a n d e l a s t i c s t r u c t u r e s ( c o r r e s p o n d i n g t o t h e S e c o n d a r yP r o c e s s ) . S o m e o f t h e c o n c e p t u a l e l e m e n t s m a y b e p r e d o m i n a n t l y v e r b al ,w h e r e a s o t h e r s m a y b e p r e d o m i n a n t l y p i c to r ia l.

M a n y o f t h e p ri m i t i v e c o n c e p t s a r e id i o s y n c r a t i c a n d u n r e a li s ti c . U n d e ro r d i n a r y w a k i n g c o n d i t i o n s , t h e s e i d i o s y n c r a t i c c o n c e p t s a p p e a r t o e x e r to n l y m i n im a l o r s p o r a d i c e f f e c t s o n t h e i n t e g r a t e d t h i n k i n g o f t h e i n d iv i d -ua l . Pecu l i a r o r i r r a t i ona l cogn i t i ons emana t i ng f rom the p r imi t i ve sy s t ema r e g e n e r a l l y t e s t e d , a u t h e n t i c a t e d , a n d r e j e c t e d b y t h e h ig h e r c e n t e r s .H o w e v e r , w h e n t h e c o g n i t iv e o r g a n i z a t io n i s d i s l o c a t e d , a s i n d e p r e s s i o n ,a n x i e t y , o r p a r a n o i d s t a t e s , t h e s e i d i o s y n c r a t i c c o n c e p t s a r e h y p e r a c t i v e .I n s u c h c ir c u m s t a n c e s , t h e c o n c e p t u a l s y s t e m s g r in d o u t a p o w e r f u ls t r e a m o f d e p r e s s i n g , f r ig h t e ni n g , o r p a r a n o i d t h o u g h t s . A s t h e s e i d i o s y n -c r a t ic i d e a s b e c o m e h y p e r a c t i v e , t h e y t e n d to s u p e r s e d e t h e m o r e r e a l is t icc o n c e p t u a l i z a t i o n s a n d t o b e c o m e m o r e r e f r a c t o r y t o r e a l i t y t e s t i n g a n dj u d g m e n t .


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COGNITIVE AND BEHAVIOR THERAPY 195T h e f o r m o f p s y c h i a t r ic d i s o r d e r i s r e l at e d t o t h e c o n t e n t o f th e p r e d o m -

i n an t , p e r s e v e r a t i n g v e r b a l c o g n i t io n s o r f a n t a s ie s . D e p r e s s e d p a t i e n ts ,f o r e x a m p l e , r e p o r t a h ig h f r e q u e n c y o f t h e m e s o f d e p r i v a t i o n o r o f s el f-d e b a s e m e n t i n t h e i r w a k i n g t h o u g h t s , d a y d r e a m s , a n d d r e a m s . A n x i o u sp a t i e n t s a r e d o m i n a t e d b y t h e c o n c e p t o f s p e c if i c o r g e n e r a li z e d p e r s o n a ld a n g e r. P a r a n o i d p a t i e n t s a r e c o n t r o l le d b y p a t t e r n s r e l e v a n t t ou n j u s t i f i e d a b u s e o r p e r s e c u t i o n . T h e p h o b i c p a t i e n t h a s a d i s p r o p o r -t i o n a t e o r u n r e a li s t ic n o t i o n o f p e r s o n a l d a n g e r i n s p e c if i c a n d a v o i d a b l es i t u a t i o n s . ( W h e n f o r c e d i n t o t h e s e s i t u a t i o n s , h e e x p e r i e n c e s a n x i e t y i nm u c h t h e s a m e w a y a s d o e s th e a n x i e t y n e u ro t ic . ) T h e c o m p u l s i v e p at ie n tis d o m i n a t e d b y d o u b t s o r b y f e a r s o f s o m e d a n g e r t o h i m s e l f o r o t h e r sa n d h e s e e k s t o p u t a n e n d t o t h e d o u b t s o r f e a r s t h r o u g h r i t u a l s .

EXPLANATION OF THERAPEUTIC CHANG EH o w d o e s t h e c o g n it iv e m o d e l p r o v i d e a n e x p l a n a t io n f o r t h e t h e r ap e u -

t ic e ff e c t s o f c o g n i t i v e o r b e h a v i o r t h e r a p y i n s t a t e s s u c h a s d e p r e s s i o n s ,a n x i e t y r e a c t i o n s , o r p h o b i a s ?

F i r s t , t h e t h e r a p e u t i c s i t u a ti o n p r o d u c e s a q u i e t in g d o w n o f t h eh y p e r a c t i v e o r g a n iz a t i o n ( R a c h m a n , 1 9 6 8 ). T h e q u i e t in g d o w n m a y b et h e r e s u l t o f e i t h e r t h e t h e r a p i s t ' s e m p a t h y a n d a c c e p t a n c e ( T r u a x &Carkh uf f , 1967 ) , h i s spec i f i c r e l axa t i on i n s t ruc t i ons (W olpe & Laz a rus ,1 9 6 6 ), o r h is e x p l i c i tl y s t a te d v e r b a l a p p r o v a l ( W a g n e r & C a u t h e n , 1 9 6 8) .T h e q u i e t i n g e f f e c t s m a y a l s o b e p r o d u c e d b y a u t o m a t e d r e l a x a t i o ni n s t ru c t i o n s ( L a n g , 1 9 6 9 ). I n t h e t r e a t m e n t o f p h o b i a s , t h e q u i e t in g e f f e c tis i n t r o d u c e d a f t e r t h e s c h e m a s r e l e v a n t t o t h e p h o b i a h a v e b e e na r ti fi ci a ll y s ti m u l a t e d b y t h e i m a g e r y i n s t ru c t i o n . A s L a d e r a n d M a t h e w s( 1 9 6 8 ) h a v e p o i n t e d o u t , r e d u c i n g t h e l e v e l o f a r o u s a l b e l o w a c e r t a in c r it -i c a l po in t t ends t o f ac i l i t a t e hab i t ua t i on (o r de sens i t i z a t i on ) .

S e c o n d , t h e t h e r a p e u t i c s e s s i o n a f f o rd s an o p p o r t u n i t y f o r t h e p a t i e n t t oe x p e r i e n c e a n d t o r e a l i t y - t e s t v e r b a l o r p i c t o r i a l c o g n i t i o n s t h a t a r ec a u s a l l y c o n n e c t e d t o h i s d e p r e s s e d o r a n x i o u s a f f e c t .

T h i s m o d e o f o p e r a t i o n m a y b e i l lu s tr a te d b y t h e t r e a t m e n t o f a p h o b i at h r o u g h s y s t e m a t i c d e s e n s i t iz a t i o n . I n t h is p r o c e d u r e , t h e p a t ie n tr e p r o d u c e s t h e p h o b i c s i t u a t io n i n h is f a n t a s i e s , a n d e x p e r i e n c e s t h e s a m et y p e o f a n x i e t y ( b u t in l e s s e r d e g r e e ) t h a t w o u l d o c c u r i f h e a c t u a l l y w e r ei n t h e p h o b i c s i t u a t io n . W h e t h e r h e i s a c t u a l l y i n t h e p h o b i c s i tu a t io n o r i ss imp ly f an t a s i z ing h im se l f i n t ha t s i t ua t i on , he believes t o s o m e d e g r e etha t he is i n dange r . Th e m ore h e be l i ev es i n t he r ea l i t y o f t he dange r , t heg r e a t e r i s h i s a n x i e t y . A t t i m e s t h e f a n t a s y m a y b e s o s t r o n g t h a t t h ep a t i e n t m a y l o s e c o g n i z a n c e o f t h e f a c t t h a t h e i s n o t a c tu a l l y i n th e p h o b i cs i t u a t i o n , a n d h e m a y e v e n s c r e a m f o r h e l p .


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196 AARON T. BECKMany patients report that their fantasy experiences are almost identical

with the actual situational experiences. The patient may live through thefrightening event in much the same way that a patient with a combat neu-rosis relives (abreacts) a combat experience under hypnosis or Amytal.

In systematic desensitization, the patient can experience the problem ingraded doses. This process enables him, first, to experience the unpleas-ant event (via imagery) and, second, to reality test his reactions in statusnascendi. Since the anxiety is not a llowed to mount up, the patient is ableto regard the event objectively. Even when flooding or implosive tech-nique (Stampfl and Levis, 1968) is employed, the patient still has the op-portunity, when the fantasy has been completed, to examine his reaction,and he soon realizes that he has been reacting to a fantasy and not to a realdanger.

Another way of viewing the process of desensitization is that thepatient is enabled to increase his objectivity, i.e., to discriminate betweena real danger and a fantasied danger as he proceeds in a stepwise progres-sion up the desensitization hierarchy. With increasing objectivity, he isless prone to misread the situation or to accept his unrealistic concep-tualization of a situation. His increased objectivity is reflected in a reduc-tion in his anxiety arousal by the imaged or the real situation (London,1964).

Patients who are questioned at the termination of an induced fantasygenerally construe the threatening situation differently and more realis-tically than previously (Beck, 1970). The operation of cognitive factors indesensitization has also been illustrated in case material cited by Brown(1967) and Weitzman (1967).

It could be argued that the phobic patient really knows that there is nodanger. However, his belief that his fear is irrational exists only when thepatient is "safely" removed from the phobic situation. When he is in thesituation, he believes to some degree that he is in danger. Desensi-tization is effective because it provides a practice session in whichthe patient is able to experience his reactions to the feared situation, labelthem as inappropriate, and gain some inner conviction that the phobic re-action is irrational.

The same mode of operation described in relation to systematic desen-sitization may be observed in the techniques of cognitive therapy. In cog-nitive psychotherapy, the patient examines his distorted ideas and istrained to discriminate between rational and irrational ideas, betweenobjective reality and internal embroidery. He is enabled to bring hisreality testing to bear and to apply judgment. He is thus able to realizewith conviction that his idiosyncratic ideas are irrational. Often the idea-tion is in the form of pictorial fantasy, and the patient is able to view the


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C O G N I T I V E A N D B E H A V I O R T H E R A P Y 197fantasy as a product o f his mind and not as a veridical representation o f areality situation.

According to this analysis, a crucial mechanism in the psycho-therapeutic chain is a modification or shift in the patient's ideationalsystem. As his irrational concept that he is paralyzed (hysteria), helplessand hopeless (depression), in danger (anxiety or phobia), persecuted(paranoid state), or superhuman (mania) becomes deactiva ted, the abnor-mal clinical picture recedes.

M E C H A N I S M O F T R A N S F E R O R G E N E R A L I Z A T I O NTrans fer of the desensi tization to the phobic situation can be explained

readily using cognitive concepts. When the untrea ted patient is placed inthe phobic situation (for example, an elevator, tunnel, or bridge), he reactsas if there were a clear and present danger to his life. His emotional reac-tion, namely anxiety, is the same that would be aroused if such a highlyprobable danger actually did exist.

For example, a woman with an elevator phobia would get the ideawhenever she entered the elevator, "There won't be enough air in hereand I will suffocate." Sometimes she would have a visual image of herselfgasping for air and suffocating. In addition, she would experience a feelingof shortness of breath. This experience occurred even when she was theonly passenger in a large, airy elevator. (The fear of elevators has adifferent content from patient to patient. Other patients believe that the el-evator cables will break during the ascent or descent, or that the elevatorwill get stuck and they will starve to death, or that they will be attacked byother people in the elevator.) When away from the elevator, however, thepatient believed that her expectation of suftication was highly unreason-able.

In the therapy session the patient imagines that he is in a phobic situa-tion. The patient with an elevator phobia, for instance, started to gasp forbreath when she was asked to imagine herself in the elevator. It appears,both from the patients' descriptions and from external observation, thatduring the fantasy the patient actually relives the situation as though itwere actually happening. In other words, the woman with the elevatorphobia who is simply imagining herself in the elevator to some degree getscarried away by the fantasy and to some degree perceives herself as in theelevator at tha t time. Hence the fear of being suffocated is stimulated eventhough she is in the safety of the consultation room.

As the patient experiences her inappropriate reaction during the desen-sitization procedure, she is able to practice viewing her fears moreobjectively.

The transfer or the generalization to the real-life situation may be


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1 9 8 A A R O N T . B E C K

explained in two ways: (a) The rehearsal effect: The patient gains experi-ence in attacking the frightening ideas and therefore, as a result of thispractice, is able to coun terac t the irrational ideas in the phobic situation;and (b) The desensitization procedure produces a significant modificationin the patient's concept of the phobic situation so that the latent fear ofbeing sufficated, etc., is obliterated.

CONCLUSIONSA question could be legitimately raised whether introducing another

system of psychotherapy is warranted. The justification is twofold. First,the theoretical framework of cognitive therapy is broader than that o f be-havior therapy and of some of the more traditional psychotherapies. Thistheoretical framework is congruent with many of the assumptions o f be-havior therapy, but provides a greater range of concepts for explainingpsychopathology as well as the mode of action of therapy. Moreover, thetheoretical structure of cognitive therapy yields hypotheses that can be(and have been) readily tested through the experimental techniquescurrently available.

Secondly, the cognitive theories provide a framework for the develop-ment of a number of therapeutic strategies that are not derivable from thepredominantly extrinsic concepts of the conditioning model. Since thesecognitive techniques, as well as the behavior techniques, are easilydefined and have demonstrated some preliminary evidence of theirefficacy in clinical practice, further exposition seems warranted.Ultimately, the strategies of psychological modification may beusefully regrouped into the cognition-oriented techniques and thebehavior-oriented techniques. The cognitive techniques would includethe methods making direct use of ideational material such as systematicdesensitization and other forms of induced imagery and in the directattempts to modify idiosyncratic cognitions. The behavioral techniqueswould include those operations of a nonintrospective nature, such as inoperant conditioning, exposure therapy, graded task assignments,roleplaying, and assertive training.

REFERENCESBECK, A. T. Thinkingand depression; 1. Idiosyncraticcontent and cognitive distortions.Archives of General Psychiatry, 1963, 9, 324-333.BECK, A. T. Depression: Clinical, experimental, and theoretical aspects. New York:Hoeber, 1967.BECK,A. T. Role of fantasies in psychotherapyand psychopathology. ournal of Nervousand Mental Disease, 1970, 150, 3-17.BRADY,J. P. Psychotherapy, earning theory,and insight.Archives of General Psychiatry,1967, 16, 304-311.


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C O G N I T I V E A N D B E H A V I O R T H E R A P Y 199B RO W N, B . M . C o g n i t i v e a s p e c t s o f W o l p e ' s b e h a v i o r t h e r a p y . American Journal of Psychi-atry, 1967 , 124 , 162-167 .C ARLSON, W. A . , TR AVERS, R . M . W. , & SC HWAB , E . A . , J R. A l a bo ra to ry a ppr oac h to the

c o g n i t iv e c o n t r o l o f a n xi e t y . P a p e r p r e s e n t e d a t t h e m e e t i n g o f t h e A m e r i c a n P e r s o n n e la n d G u i d a n c e A s s o c i a t i o n , L a s V e g a s , M a r c h 1 9 6 9 .D A V lS O N, G . C . S y s t e m a t i c d e s e n s i t i z a t i o n a s a c o u n t e r - c o n d i t i o n i n g p r o c e s s . Journal ofAbnormal Psychology, 1 9 6 8 , 7 3 , 9 1 - 9 9 .E L LI S, A . O u t c o m e o f e m p l o y i n g t h r e e t e c h n i q u e s o f p s y c h o t h e r a p y . Journal o f Clinical

Psychology, 1 9 5 7 , 1 3, 3 4 4 - 3 5 0 .ELLlS, A. Reason and emotion in psychotherapy. N e w Y o r k : L y l e S tu a r t , 1 9 62 .FOLKINS, C . H . , LAWSON, K . D . , OPTON, E . M . , & LAZAR US, R . S . De s en s i t i z a t ion o f the

e x p e r i m e n t a l r e d u c t i o n o f t h r e a t. Journal o fA bnormal Psychology, 1968 , 73 , 100-113 .FRANK, J . n . Persuasion and healing. B a l t i m o r e : J o h n s H o p k i n s P r e s s , 1 9 6 1 .HARVEY, O. J . , HUNT, D . E. , SCHRODER, H. i . Conceptual systems and personality or-

ganization. N e w Y o r k : W i l e y , 1 9 6 1 .JONES, R . G . A f a c t o r e d m e a s u r e o f E l l i s ' i r r a t i o n a l b e l i e f s y s t e m w i t h p e r s o n a l i t y a n d m a l -a d j u s t m e n t c o r r e la t e s . D o c t o r a l d i s s e r t a ti o n , T e x a s T e c h n o l o g i c a l C o ll e g e, L u b b o c k ,

T e x a s , 1 9 6 8 .K R IP PN E R, S . R e l a t i o n s h i p b e t w e e n r e a d i n g i m p r o v e m e n t a n d t e n s e l e c t e d v a r i a b l e s . Per-ceptual and Motor Skills, 1964 , 19 , 15 -20 .L A D ER , M . H . , t g. M A T H E W S, A . M . A p h y s i o l o g i c a l m o d e l o f p h o b i c a n x i e t y a n d d e s e n s i -

t i z a t i o n . Behaviour Research and Therapy, 1 9 6 8 , 6 , 4 1 1 - 4 2 1 .L A NG , P . J. T h e m e c h a n i c s o f d e s e n s i t i z a t i o n a n d t h e l a b o t a r o r y s t u d y o f h u m a n f e a r. I n C .

M . F r a n k s ( E d . ) , Behavior therapy: appraisal and status. N e w Y o r k : M c G r a w - H i l l ,1 9 6 9 . P p . 1 6 0 - 1 9 1 .

L A ZA R US , A . V a r i a t i o n s i n d e s e n s i t i z a t i o n t h e r a p y . Psychotherapy: Theory, research andpractice, 1 9 6 8 , 5 , 5 0 - 5 2 .

LEITENB ER G, H . , AGR AS, W. S . , B AR LOW, D . H . , & OLIVEAU, n . C . C o n t r ibu t ion o f s e l ec -t i v e p o si t i v e r e i n f o r c e m e n t a n d t h e r a p e u t i c i n s t r u c ti o n s t o s y s t e m a t ic d e s e n s i t i z a ti o nt h e r a p y . Journal of Abnormal Psychology, 1 9 6 9 , 7 4 , 1 1 3 - 1 1 8 .

LOEB , A . , B EC K, A . T . , DIGGOR Y, J . C . , & TUTHILL, R . Ex pec tenc y , l eve l o f a s p i ra t ion , pe r -f o r m a n c e , a n d s e l f - e v a l u a t i o n i n d e p r e s s i o n . Proceedings o f the Annual Convention,American Psychological Association, 1 9 6 7 , 2 , 1 9 3 - 1 9 4 .

LONDON, P. The modes and morals of psychotherapy. N e w Y o r k : H o l t , R i n e h a r t &W i n s t o n , 1 9 6 4 .

MISCHEL, W . Personality and assessment. N e w Y o r k : W i l e y , 1 9 6 8 .M U RR AY , E . J . , & J A CO BS ON , L . T . T h e n a t u r e o f l e a r n i n g i n t r a d i t i o n a l a n d b e h a v i o r a l p s y -

c h o t h e r a p y . I n A . E . B e r g i n & S . L . G a r f i e l d ( E d s . ) , Handbook of psychotherapy andbehavior change. N e w Y o r k : W i l e y , 1 9 6 9 .RACHMAN, S . T h e r o l e o f m u s c u l a r r e l a x a t i o n i n d e s e n s i t i z a t i o n t h e r a p y . BehaviourResearch and Therapy, 1 9 6 8 , 6 , 1 5 9 - 1 6 6 .R IM M , D . C . , & L IT V A K , S . B . S e l f - v e r b a l i z a t i o n a n d e m o t i o n a l a r o u s a l . Journal of Abnor-real Psychology, 1 9 6 9 , 7 4 , 1 8 1 - 1 8 7 .SLOANE,R . B . C o n v e r g i n g p a t h s o f b e h a v i o r th e r a p y a n d p s y c h o t h e r a p y . American Journalof Psychiatry, 1969 , 125 , 877-885 .

STAMPFL, T. G., t ~ L E V IS , D . J . I m p l o s i v e t h e r a p y : A b e h a v i o r a l t h e r a p y ? BehaviourResearch and Therapy, 1 9 6 8 , 6 , 3 1 - 3 6 .T R EX L ER , L . D . , t ~ K A RS T , T . O . T h e u s e o f f i x e d - r o le a n d r a t i o n a l - e m o t i v e t h e r a p y i n t r e a t -

i n g p u b l i c - s p e a k i n g a n x i e t y . P a p e r p r e s e n t e d a t t h e m e e t i n g o f t h e E a s t e r n P s y -c h o l o g i c a l A s s o c i a t i o n , P h i l a d e l p h i a , A p r i l 1 9 6 9 .


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TR UAX, C . B . , & C AR KHUFF, R . R . Toward effective counseling and psychotherapy: Train-ing and practice. C h i c a g o : A l d i n e , 1 9 6 7 .VALINS, S., R A Y , A . E f f e c t s o f c o g n i t i v e d e s e n s i t i z a t i o n o n a v o i d a n c e b e h a v i o r . Journal

of Personality and Social Psychology, 1 9 6 7 , 7 , 3 4 5 - 3 5 0 .V E L T EN , E . A l a b o r a t o r y t a s k f o r i n d u c t i o n o f m o o d s t a t e s . Behaviour Research andTherapy, 1 9 6 8 , 6 , 4 7 3 - 4 8 2 .W A G N ER , M . K . , & C A U T HE N , N . R . C a s e h i s t o r i e s a n d s h o r t e r c o m m u n i c a t i o n s . BehaviourResearch and Therapy, 1 9 6 8 , 6 , 2 2 5 - 2 2 7 .WEITZMAN,B . B e h a v i o r t h e r a p y a n d p s y c h o t h e r a p y . Psychological Review, 1 9 6 7 , 7 4 , 3 0 0 -

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neuroses. N e w Y o r k : P e r g a m o n P r e ss , 1 9 6 6.

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