COGNITIVE BEHAVIORAL COGNITIVE BEHAVIORAL THERAPYTHERAPY

Lecture 34Lecture 34

BACKGROUNDBACKGROUND

We now find coverage of concepts and terms such as We now find coverage of concepts and terms such as cognitive-behavior cognitive-behavior modification, modification, cognitive cognitive restructuring, restructuring, stress inoculation, and stress inoculation, and rational rational restructuring.restructuring.

A cognitive perspective on clinical problems A cognitive perspective on clinical problems emphasizes the role of thinking in the etiology and emphasizes the role of thinking in the etiology and maintenance of problems.maintenance of problems.

Cognitive-Behavioral techniques have a great deal of Cognitive-Behavioral techniques have a great deal of empirical support and are seen as among the most empirical support and are seen as among the most effective of all psychological interventions.effective of all psychological interventions.

Brief HistoryBrief History

THE MOVE TOWARDS THE MOVE TOWARDS COGNITIVE-COGNITIVE-

BEHAVIORALBEHAVIORALAPPROACHESAPPROACHES

Although several effective treatments based on Although several effective treatments based on traditional behavioral learning principles had been traditional behavioral learning principles had been developed, by the early 1970s it was clear that a developed, by the early 1970s it was clear that a number of frequently encountered clinical conditions number of frequently encountered clinical conditions (such as depression) were not so easily addressed by (such as depression) were not so easily addressed by treatments based on classical or operant conditioning.treatments based on classical or operant conditioning.

In a sense, the present blending of behavioral and In a sense, the present blending of behavioral and cognitive methods was stimulated by the limitations of cognitive methods was stimulated by the limitations of both psychodynamics and radical behaviorism. both psychodynamics and radical behaviorism.

This blending was also facilitated by the presence of This blending was also facilitated by the presence of several theoretical models that incorporated cognitive several theoretical models that incorporated cognitive variables along with the scientific and experimental variables along with the scientific and experimental rigor so precious to behaviorists.rigor so precious to behaviorists.

THE ROLE OF SOCIAL LEARNING THEORYTHE ROLE OF SOCIAL LEARNING THEORY::

Rotter's social learning theory was a theory that Rotter's social learning theory was a theory that explained behavior as a joint product of both explained behavior as a joint product of both reinforcement and expectances.reinforcement and expectances.

The presence of such a social learning theory did at The presence of such a social learning theory did at least two things for the development of behavior least two things for the development of behavior therapy. therapy.

First, it produced a number of clinicians (and First, it produced a number of clinicians (and influenced others) who were ready to accept newer influenced others) who were ready to accept newer behavioral techniques and were equipped with a behavioral techniques and were equipped with a theoretical point of view that could facilitate the theoretical point of view that could facilitate the modification of those techniques along more cognitive modification of those techniques along more cognitive lines. lines.

Second, the theory, being both cognitive and Second, the theory, being both cognitive and motivational, was capable of blending the older motivational, was capable of blending the older psychodynamically derived therapeutic procedures psychodynamically derived therapeutic procedures with the newer behavioral and cognitive approaches.with the newer behavioral and cognitive approaches.

By its very presence, then, social learning theory By its very presence, then, social learning theory facilitated a fusion of approaches that is still in facilitated a fusion of approaches that is still in progress. progress.

In evaluating the relevance of this social learning In evaluating the relevance of this social learning theory for the practice of both traditional theory for the practice of both traditional psychotherapy and behavior therapy, consider the psychotherapy and behavior therapy, consider the following implications discussed by Rotter (1970):following implications discussed by Rotter (1970):

1. Psychotherapy is regarded as a learning 1. Psychotherapy is regarded as a learning situation, and the role of the therapist is to situation, and the role of the therapist is to enable the patient to achieve planned changes enable the patient to achieve planned changes in observable behavior and thinking.in observable behavior and thinking.

2. A problem-solving framework is a useful way 2. A problem-solving framework is a useful way in which to view most patients' difficulties.in which to view most patients' difficulties.

3. Most often, the role of the therapist is to 3. Most often, the role of the therapist is to guide the teaming process so that not only are guide the teaming process so that not only are inadequate behaviors and attitudes weak ened inadequate behaviors and attitudes weak ened but more satisfying and constructive behaviors but more satisfying and constructive behaviors are learned.are learned.

4. It is often necessary to change unrealistic 4. It is often necessary to change unrealistic expectancies; in so doing, one must realize how it was expectancies; in so doing, one must realize how it was that certain behaviors and expectancies arose and that certain behaviors and expectancies arose and how prior experience was misapplied or over how prior experience was misapplied or over generalized by the patient. generalized by the patient.

5. In therapy, the patient must learn to be concerned 5. In therapy, the patient must learn to be concerned with the feelings, expectations, motives, and needs of with the feelings, expectations, motives, and needs of others.others.

6. New experiences or different ones in real life can 6. New experiences or different ones in real life can often be much more effective than those that occur often be much more effective than those that occur only during the therapy situation.only during the therapy situation.

7. In general, therapy is a kind of social interaction.7. In general, therapy is a kind of social interaction.

Cognitive-behavioral Cognitive-behavioral Treatment ApproachesTreatment Approaches

MODELINGMODELING

Bandura (1969, 1971) has advocated the use Bandura (1969, 1971) has advocated the use of of modeling, modeling, or observational learning, particularly or observational learning, particularly in children .in children .

Imitation, Modeling or observation are much Imitation, Modeling or observation are much more efficient techniques for learning than is a more efficient techniques for learning than is a simple reliance on punishment for incorrect simple reliance on punishment for incorrect responses and reward for correct ones.responses and reward for correct ones.

Through observation one can learn to use Through observation one can learn to use behaviors that are already part of the behaviors that are already part of the behavioral repertoire.behavioral repertoire.

Perhaps the most widespread use of modeling Perhaps the most widespread use of modeling has been to eliminate unrealistic fears.has been to eliminate unrealistic fears.

Phobias (especially snake phobias have been Phobias (especially snake phobias have been the principal means both the principal means both of of demonstrating and demonstrating and of investigating modeling techniques. of investigating modeling techniques.

In participant modeling, for example, the patient In participant modeling, for example, the patient observes the therapist or model holding a observes the therapist or model holding a snake, allowing the snake to crawl over the snake, allowing the snake to crawl over the body, and so on. Next, in guided participation, body, and so on. Next, in guided participation, the patient is exhorted to try out a series of the patient is exhorted to try out a series of similar activities, graded according to their similar activities, graded according to their potential for producing anxiety. potential for producing anxiety.

As noted by Thorpe and Olson (1997), observational As noted by Thorpe and Olson (1997), observational learning is best and most efficient when the following learning is best and most efficient when the following four conditions are met:four conditions are met:

1. Patients attend to the model. Incentives may be 1. Patients attend to the model. Incentives may be helpful to facilitate attention.helpful to facilitate attention.

2. Patients retain the information provided by the model. 2. Patients retain the information provided by the model. It may be helpful to use imagery techniques or verbal It may be helpful to use imagery techniques or verbal coding strategies to help patients organize and retain coding strategies to help patients organize and retain the information provided.the information provided.

3. Patients must perform the modeled behavior. It is 3. Patients must perform the modeled behavior. It is important that the behavior be mim icked and practiced important that the behavior be mim icked and practiced to facilitate learning and behavior change.to facilitate learning and behavior change.

4. Finally, patients must be motivated to use the 4. Finally, patients must be motivated to use the behavior that is modeled. It is suggested that behavior that is modeled. It is suggested that reinforcing consequences be used to increase the reinforcing consequences be used to increase the likelihood that the modeled be havior will be used.likelihood that the modeled be havior will be used.

RATIONAL RESTRUCTURINGRATIONAL RESTRUCTURING:-:- Goldfried and Davison 1994) accept the notion that Goldfried and Davison 1994) accept the notion that

much maladaptive behavior is determined by the ways much maladaptive behavior is determined by the ways in which people construe their world or by the in which people construe their world or by the assumptions they make about it. assumptions they make about it.

If this is true, it follows that the behavior therapist must If this is true, it follows that the behavior therapist must help patients learn to label situations more realistically help patients learn to label situations more realistically so that they can ultimately attain greater satisfaction.so that they can ultimately attain greater satisfaction.

To facilitate this ratioTo facilitate this rational restructuring nal restructuring of events, the of events, the therapist may sometimes use argument or discussion therapist may sometimes use argument or discussion in an attempt to get patients to see the irrationality of in an attempt to get patients to see the irrationality of their beliefs. their beliefs.

Therapist may attempt to teach them to "modify their Therapist may attempt to teach them to "modify their internal sentences."internal sentences."

Thus, rational restructuring is not a self-contained, Thus, rational restructuring is not a self-contained, theoretically derived procedure, but an eclectic series theoretically derived procedure, but an eclectic series of techniques that can be tailored to suit the particular of techniques that can be tailored to suit the particular demands of the patient's situation.demands of the patient's situation.

A good example of rational restructuring is Ellis's A good example of rational restructuring is Ellis's (1962) (1962) rational-emotive therapyrational-emotive therapy (RET).(RET).

RET aims to change behavior by altering the way the RET aims to change behavior by altering the way the patient thinks about things.patient thinks about things.

According to Ellis, all behavior, whether maladjusted According to Ellis, all behavior, whether maladjusted or otherwise, is determined not by events but by the or otherwise, is determined not by events but by the person's interpretation of those events.person's interpretation of those events.

In the ABCs of RET, Ellis argues that it is In the ABCs of RET, Ellis argues that it is beliefs (B)beliefs (B) about about activating eventsactivating events or situationsor situations (A) (A) that determine the problematic emotional or behavioral that determine the problematic emotional or behavioral

consequences (C).consequences (C).

In a sense, the basic goal of RET is to make In a sense, the basic goal of RET is to make people confront their own illogical thinking. people confront their own illogical thinking.

Ellis tries to get the client to use common Ellis tries to get the client to use common sense. sense.

The therapist becomes an active and directive The therapist becomes an active and directive teacher. teacher.

Reviews of the empirical literature suggest that Reviews of the empirical literature suggest that RET is an effective psychological intervention RET is an effective psychological intervention (Smith, et al., 1980). (Smith, et al., 1980).

However, more detailed investigation of the However, more detailed investigation of the components of RET that lead to change in components of RET that lead to change in clinical status have has been called for (Haaga clinical status have has been called for (Haaga & Davison, 1993).& Davison, 1993).

STRESS INOCULATION TRAININGSTRESS INOCULATION TRAINING:-:- Based on his own research, which indicated that Based on his own research, which indicated that

patients could use self-talk or self-instruction to modify patients could use self-talk or self-instruction to modify their behavior and that therapists could, in effect, train their behavior and that therapists could, in effect, train patients to change their self-talk, patients to change their self-talk,

Meichenbaum (1977) developed Meichenbaum (1977) developed stress inoculation stress inoculation trainingtraining (SIT).(SIT).

SIT aims to prevent problems from developing by. SIT aims to prevent problems from developing by. ‘’inoculating" individuals to ongoing and future ‘’inoculating" individuals to ongoing and future stressors. stressors.

It is designed to help individuals develop new coping It is designed to help individuals develop new coping skills and make full use of the coping strategies that skills and make full use of the coping strategies that are already in place . are already in place .

SIT for coping with stressors appears onSIT for coping with stressors appears on the most the most recent list of examples of empirically supported recent list of examples of empirically supported treatment.treatment.

SIT proceeds in three overlapping phases SIT proceeds in three overlapping phases (Meichenbaum, 1996):(Meichenbaum, 1996):

1. 1. Conceptualization phase: -Conceptualization phase: - First, the client is First, the client is educated with regard to how certain thinking or educated with regard to how certain thinking or appraisal patterns lead to stress, other negative appraisal patterns lead to stress, other negative emotions, and dysfunctional behavior. The client is emotions, and dysfunctional behavior. The client is taught how to identify potential threats or stressors taught how to identify potential threats or stressors and how to cope with them.and how to cope with them.

2.2. Skill acquisition and rehearsal phase Skill acquisition and rehearsal phase: - : - The client The client practices coping skills (for example, emotional self-practices coping skills (for example, emotional self-regulation, cognitive restructuring, using support regulation, cognitive restructuring, using support systems) in the clinic and then gradually out in the systems) in the clinic and then gradually out in the "real world" as he or she is confronted with the "real world" as he or she is confronted with the stressors.stressors.

3. 3. Application phase: -Application phase: - Additional opportunities arise Additional opportunities arise for the client to apply a wide variety of coping skills for the client to apply a wide variety of coping skills across a range of stressful conditions. In order to across a range of stressful conditions. In order to consolidate these skills, the client may be asked to consolidate these skills, the client may be asked to help others who are experiencing similar problems. help others who are experiencing similar problems.

Further "in oculation" procedures, including relapse Further "in oculation" procedures, including relapse prevention and booster sessions, are incorporated prevention and booster sessions, are incorporated during the follow-up period.during the follow-up period.

To give one concrete example, Novaco To give one concrete example, Novaco (1977) (1977) describes the application of stress inoculation describes the application of stress inoculation procedures to deal with the anger problems of procedures to deal with the anger problems of depressed patients on acute psychiatric wards.depressed patients on acute psychiatric wards.

BECK’S COGNITIVE THERAPY:-BECK’S COGNITIVE THERAPY:- Aaron Beck has been a pioneer in the development of Aaron Beck has been a pioneer in the development of

cognitive-behavioral treatments for a variety of clinical cognitive-behavioral treatments for a variety of clinical problems. problems.

This model of intervention entails the use of both This model of intervention entails the use of both cognitive and behavioral techniques to modify cognitive and behavioral techniques to modify dysfunctional thinking patterns that characterize the dysfunctional thinking patterns that characterize the problem or disorder in question problem or disorder in question . .

For example, depressed individuals are believed to For example, depressed individuals are believed to harbor negative/pessimistic beliefs about themselves, harbor negative/pessimistic beliefs about themselves, their world, and their future. their world, and their future.

Example of 45-year-old man who is prone to be highly Example of 45-year-old man who is prone to be highly self-critical (and often feel guilty, even when it is not self-critical (and often feel guilty, even when it is not appropriate), to view the world as generally appropriate), to view the world as generally unsupportive and unfair, and not to hold much hope that unsupportive and unfair, and not to hold much hope that things will improve in the future.things will improve in the future.

The following The following cognitive therapy (CT)cognitive therapy (CT)techniques techniques might be used in the treatment of his depression.might be used in the treatment of his depression.

1. Scheduling activities to counteract his relative 1. Scheduling activities to counteract his relative inactivity and tendency to focus on his depressive inactivity and tendency to focus on his depressive feelings.feelings.

2. 2. Increasing the rates of pleasurable activities as well Increasing the rates of pleasurable activities as well as of those in which some degree of mastery is as of those in which some degree of mastery is experienced.experienced.

3. 3. Cognitive rehearsal:Cognitive rehearsal: Have the patient imagine each Have the patient imagine each successive step leading to the completion of an successive step leading to the completion of an important task (such as attending an exercise class), important task (such as attending an exercise class), so that potential impediments can be identified, so that potential impediments can be identified, anticipated, and addressed.anticipated, and addressed.

4. Assertiveness training and role playing.4. Assertiveness training and role playing.

5. Identifying automatic thoughts that occur before or 5. Identifying automatic thoughts that occur before or during dysphoric episodes (for example, "I can't do during dysphoric episodes (for example, "I can't do anything right").anything right").

6. Examining the reality or accuracy of these thoughts by 6. Examining the reality or accuracy of these thoughts by eat challenging their validity ("So you don't think there eat challenging their validity ("So you don't think there is is anything you anything you can do right?").can do right?").

7. 7. Teaching the patient to reattribute the "blame" for Teaching the patient to reattribute the "blame" for negative consequences to the appropriate source. negative consequences to the appropriate source. Depressed patients have a tendency to blame Depressed patients have a tendency to blame themselves for negative outcomes, even when they themselves for negative outcomes, even when they are not to blame.are not to blame.

8. Helping the patient search for alternative so lutions to 8. Helping the patient search for alternative so lutions to his problems instead of resigning himself to their his problems instead of resigning himself to their insolubility.insolubility.

It is worth repeating that cognitive therapy has It is worth repeating that cognitive therapy has proven to be one of the most effective proven to be one of the most effective techniques available for treating depression . techniques available for treating depression .

In addition, cognitive therapy has been adapted In addition, cognitive therapy has been adapted for use with patients suffering from anxiety for use with patients suffering from anxiety disorders (Beck & Emery, 1985), eating disorders (Beck & Emery, 1985), eating disorders (Fairburn et al., 1991), and disorders (Fairburn et al., 1991), and personality disorders (Beck, Freeman, & personality disorders (Beck, Freeman, & Associates, 1990), to cite but a few examples. Associates, 1990), to cite but a few examples.

Empirical studies suggest that it may be an Empirical studies suggest that it may be an especially effective form of intervention for a especially effective form of intervention for a broad range of clinical problems (Hollon & broad range of clinical problems (Hollon & Beck, 1994; Smith et al., 1980)Beck, 1994; Smith et al., 1980)

AN EVALUATION OF THE AN EVALUATION OF THE BEHAVIORAL THERAPYBEHAVIORAL THERAPY

Proponents of behavior therapy see their progress as Proponents of behavior therapy see their progress as tangible evidence of what can be accomplished when tangible evidence of what can be accomplished when the mentalistic, subjective, and nonscientific "mumbo the mentalistic, subjective, and nonscientific "mumbo jumbo" of psychodynamics or phenomenology is cast jumbo" of psychodynamics or phenomenology is cast aside. aside.

Critics, on the other hand, see behavior therapy as Critics, on the other hand, see behavior therapy as superficial, pretentiously scientific, and even superficial, pretentiously scientific, and even dehumanizing in its mechanistic attempts to change dehumanizing in its mechanistic attempts to change human behavior. human behavior.

Indeed, these criticisms reflect many of the "myths" Indeed, these criticisms reflect many of the "myths" about behavior therapy.about behavior therapy.

In any case, more clinical psychologists describe their In any case, more clinical psychologists describe their orientation as cognitive or behavioral than any other orientation as cognitive or behavioral than any other orientation.orientation.

STRENGTHS:STRENGTHS:There is ample evidence that a wide variety of There is ample evidence that a wide variety of behavioral and cognitive-behavioral therapies are behavioral and cognitive-behavioral therapies are effective. effective.

Treatment of choice for many disorder.Treatment of choice for many disorder. On average, a client who received any of behavior On average, a client who received any of behavior

therapy was functioning better than at least 75% of therapy was functioning better than at least 75% of those who did` not receive any treatment. those who did` not receive any treatment.

Further, the majority of meta-analytic studies that have Further, the majority of meta-analytic studies that have compared the effectiveness of behavioral or cognitive-compared the effectiveness of behavioral or cognitive-behavioral techniques with that of other forms of behavioral techniques with that of other forms of psychotherapy have found a small but consistent psychotherapy have found a small but consistent superiority for behavioral and cognitive-behavioral superiority for behavioral and cognitive-behavioral methods.methods.

EFFICIENCY:EFFICIENCY: The behavior therapy movement also brought The behavior therapy movement also brought

with it a series of techniques that were shorter with it a series of techniques that were shorter and more efficient.and more efficient.

Shorter time focused on the patient's specific Shorter time focused on the patient's specific complaints. complaints.

An emphasis was given on the present and a An emphasis was given on the present and a pragmatism that was signaled by the use of pragmatism that was signaled by the use of specific techniques for specific problems.specific techniques for specific problems.

Because of its efficiency, behavior therapy may Because of its efficiency, behavior therapy may be especially well suited for the managed care be especially well suited for the managed care environment (Wilson, 1997).environment (Wilson, 1997).

In fact, some behavioral techniques can be In fact, some behavioral techniques can be implemented by Technicians who are trained to work implemented by Technicians who are trained to work under the supervision of a doctoral-level clinician. under the supervision of a doctoral-level clinician.

Thus, not every component of behavior therapy needs Thus, not every component of behavior therapy needs to be executed by Ph.D. personnel. to be executed by Ph.D. personnel.

Behavior therapy programs (for example, token Behavior therapy programs (for example, token economies) should be set up by trained professionals, economies) should be set up by trained professionals, but their day-to-day execution can be put in the hands but their day-to-day execution can be put in the hands of technicians, paraprofessionals, nurses, and others. of technicians, paraprofessionals, nurses, and others. This constitutes a considerable savings in mental This constitutes a considerable savings in mental health personnel and enables a larger patient health personnel and enables a larger patient population to be reached than can be treated by the population to be reached than can be treated by the in-depth, one-on-one procedures of an exclusively in-depth, one-on-one procedures of an exclusively psychodynamic approach.psychodynamic approach.

It is also worth repeating that behavior therapy It is also worth repeating that behavior therapy is the undisputed leader in "manualizing" its is the undisputed leader in "manualizing" its treatments.treatments.

Not only does this facilitate conducting Not only does this facilitate conducting research and providing effective treatment, but research and providing effective treatment, but it also facilitates the training of future clinical it also facilitates the training of future clinical psychologists to administer these effective psychologists to administer these effective treatments.treatments.

BREADTH OF APPLICATIONBREADTH OF APPLICATION: :

A contribution of major proportions has been the A contribution of major proportions has been the extension of the range of applicability of therapy. extension of the range of applicability of therapy.

Traditional psychotherapy had been reserved for the Traditional psychotherapy had been reserved for the middle and upper classes. Behavior therapy has middle and upper classes. Behavior therapy has changed all that.changed all that.

Now, even financially strapped individuals with mental Now, even financially strapped individuals with mental retardation or a chronic mental illness can be helped retardation or a chronic mental illness can be helped by therapy.by therapy.

Not only the institutionalized have benefited from Not only the institutionalized have benefited from behavioral techniques.behavioral techniques.

In cases where lengthy verbal psychotherapies that In cases where lengthy verbal psychotherapies that were highly dependent on insight, symbolism, or the were highly dependent on insight, symbolism, or the release of some inner potential were likely to fail, a release of some inner potential were likely to fail, a broad band of behavior therapies seems to offer real broad band of behavior therapies seems to offer real hope.hope.

CriticismCriticism

1. DEHUMANIZING1. DEHUMANIZING: -: - Among the more durable characterizations of the Among the more durable characterizations of the

behavioral-movement are ‘’Sterile," "mechanistic,' and behavioral-movement are ‘’Sterile," "mechanistic,' and "dehumanizing. "dehumanizing.

Wool Folk demonstration of undergraduates.Wool Folk demonstration of undergraduates. The use of mechanistic-sounding terms such as The use of mechanistic-sounding terms such as

response, stimulus, reinforcement, response, stimulus, reinforcement, and and operantoperant need need not imply that either the therapist or the method is not imply that either the therapist or the method is detached, sterile, or dehumanizing. detached, sterile, or dehumanizing.

The systematic use of learning principles and the The systematic use of learning principles and the examination of animal analogues for simple examination of animal analogues for simple illustrations to highlight the nature of human learning illustrations to highlight the nature of human learning should not lead to a facile inference that behavior should not lead to a facile inference that behavior therapists are cold, manipulating robots whose therapists are cold, manipulating robots whose interests lie more in their learning principles than in interests lie more in their learning principles than in their clients.their clients.

Although nothing inherent in behavior therapy Although nothing inherent in behavior therapy should lead one to conclude that it is should lead one to conclude that it is necessarily dehumanizing, its early history necessarily dehumanizing, its early history provided a few unfortunate episodes and a provided a few unfortunate episodes and a considerable stridency of rhetoric.considerable stridency of rhetoric.

We know the use of aversion techniques that We know the use of aversion techniques that to many seemed more akin to sadism than to many seemed more akin to sadism than therapy. therapy.

In addition, many early behaviorists seemed to In addition, many early behaviorists seemed to be so obsessed with their principles and their be so obsessed with their principles and their technology that common sense seemed to be technology that common sense seemed to be the chief casualty.the chief casualty.

Their sometimes naive attacks on Their sometimes naive attacks on psychodynamics and their zealous psychodynamics and their zealous overconfidence in technology often played overconfidence in technology often played right into the hands of their critics and only right into the hands of their critics and only served to make life more difficult for their served to make life more difficult for their successors.successors.

In the final analysis, no technology or set of In the final analysis, no technology or set of principles is going to permit clinicians the principles is going to permit clinicians the luxury of giving up their clinical sensitivity.luxury of giving up their clinical sensitivity.

2. INNER GROWTH2. INNER GROWTH: -: - Behavior therapy has also been criticized as Behavior therapy has also been criticized as

ameliorative but not productive of any inner growth. ameliorative but not productive of any inner growth. It has been said to relieve symptoms or provide a few It has been said to relieve symptoms or provide a few

skills while failing to offer fulfilling creative skills while failing to offer fulfilling creative experiences. experiences.

Although it may, alter behavior, it falls short of Although it may, alter behavior, it falls short of promoting understanding. It eaves out the inner promoting understanding. It eaves out the inner person, values, responsibility, and motives. person, values, responsibility, and motives.

Again, though not completely off the mark, such Again, though not completely off the mark, such criticisms are less appropriate for the newer cognitive criticisms are less appropriate for the newer cognitive emphasis in behavior therapy, an emphasis that does emphasis in behavior therapy, an emphasis that does deal with mediating variables such as expectancies deal with mediating variables such as expectancies and self-concepts--as long as these are objectively and self-concepts--as long as these are objectively describable and are inferred from specific stimuli and describable and are inferred from specific stimuli and responses.responses.

4. MENTAL PROCESSES4. MENTAL PROCESSES:: Although few behavior therapists can be said to embrace Although few behavior therapists can be said to embrace

the unconscious, only the radical behaviorists still insist the unconscious, only the radical behaviorists still insist on the absolute rejection of all so called mental on the absolute rejection of all so called mental processes. processes.

Likewise, not many behavioral clinicians are likely to Likewise, not many behavioral clinicians are likely to recommend an exhaustive reconstruction of the patient's recommend an exhaustive reconstruction of the patient's past . past .

But this is not to argue that past learning experiences But this is not to argue that past learning experiences have not led to the patient's current predicament. Indeed have not led to the patient's current predicament. Indeed they have. they have.

Any sensitive behavioral clinician will devote time to Any sensitive behavioral clinician will devote time to understanding what those learning experiences were all understanding what those learning experiences were all about. about.

By so doing, the clinician can better distinguish between By so doing, the clinician can better distinguish between behavioral deficits and problems and can better behavioral deficits and problems and can better understand how to structure present learning experiences understand how to structure present learning experiences so as to enable patients to better cope with their so as to enable patients to better cope with their problems. problems.

5. MANIPULATION AND CONTROL5. MANIPULATION AND CONTROL: : One of the most volatile, emotion-laden criticisms of One of the most volatile, emotion-laden criticisms of

behavior therapy centers on the issue of manipulation behavior therapy centers on the issue of manipulation and control. and control.

The argument seems to be that behavior therapies The argument seems to be that behavior therapies represent insidious and often direct assaults on the represent insidious and often direct assaults on the patient's capacity to make decisions, assume patient's capacity to make decisions, assume responsibility, and maintain dignity and integrity. responsibility, and maintain dignity and integrity.

But patients typically seek professional assistance But patients typically seek professional assistance voluntarily, thereby acknowledging their need for help voluntarily, thereby acknowledging their need for help and guidance in altering their lives. and guidance in altering their lives.

Thus, the patient does have the opportunity to accept Thus, the patient does have the opportunity to accept or reject the procedures offered. or reject the procedures offered.

Further, many behavior therapy techniques are aimed Further, many behavior therapy techniques are aimed at helping patients establish skills that will lead to at helping patients establish skills that will lead to greater self direction and self control.greater self direction and self control.

6. GENERALIZATION: 6. GENERALIZATION: Do the effects of behavior therapy programs Do the effects of behavior therapy programs

generalize beyond the situations in which they generalize beyond the situations in which they are practiced?are practiced?

Again, in the interests of even handedness, it Again, in the interests of even handedness, it should be pointed out that most forms of should be pointed out that most forms of psychotherapy is subject to the same question.psychotherapy is subject to the same question.

For example, some patients show a marked For example, some patients show a marked improvement or adjustment in the improvement or adjustment in the psychotherapy situation even though this psychotherapy situation even though this adjustment fails to generalize to non-therapy adjustment fails to generalize to non-therapy settings.settings.

It is the operant approaches that have been It is the operant approaches that have been most suspects heremost suspects here