Cognitive-Behavioral Psychotherapies: Part 1

cbt diagram

“Men are disturbed not by things, but by the view which they take of them.”

Epictetus Enchiridion

Over the past 50 years, no psychotherapeutic methodology has been more researched than those that fall under the umbrella of cognitive-behavioral therapy. Over the past several decades, there have been thousands of studies that have shown cognitive-behavioral psychotherapies yield superior outcomes to other psychotherapeutic approaches.  These results apply to the treatment of anxiety disorders, addiction, eating, and some personality disorders. Additionally, cognitive-behavioral approaches are shown to be the treatment of choice for therapists working with clients who struggle with insomnia, pain management, mood disorders and PTSD.
All cognitive-behavioral therapies, as can be inferred from the name, approach intervention from both a cognitive (thinking/covert), and behavioral (physical/overt) orientation.1 What these therapies also have in common is their emphasis on the “here and now,” that is, what are the circumstances of the client’s current functioning, and what can be done in an expedient timeframe to facilitate improvement.  With this said, a thorough exploration of a clients’ historical information is essential if a therapist is to accurately diagnose and develop an appropriate treatment plan.


Sigmond Freud father of Psychotherapies

Prior to and into the early twentieth century, physicians exclusively practiced the field of psychology. Psychoanalytic psychotherapy, the development of which is attributed to Sigmond Freud, was the dominant form of psychotherapy being practiced at that time. Psychoanalysis is a form of in-depth talk therapy that aims to bring what is unconscious to consciousness. It is based on the theory that repressed experiences and emotions, often from childhood, along with inborn urges, dramatically influence how an individual views and operates in the world, and if these experiences and urges are not brought to consciousness, the individual will continue to suffer neurosis and internal strife.

Shortly after the turn of century, many psychiatrists and psychologists became disillusioned with the lack of objective evidence demonstrating that psychoanalysis was creating positive change. They believed that a field of medicine in which unobservable mechanisms were being inferred, and, where proof of outcome was limited to the subjective observations of doctors and informal reporting by patients, was not practicing good science. This, along with the need for interventions that could yield results in a shorter period of treatment, (In general, psychoanalysis is a process that has the client being seen several times a week for many years), brought about the rise of behaviorism. Focused exclusively on observable behavior that could be objectively quantified, behaviorism moved psychotherapy toward being viewed as an evidence-based practice.


Behaviorism:  The theory that human or animal behavior is based on conditioning (mental training and the influence of habit), rather than being explained by thoughts and feelings

Cambridge Dictionary

Behaviorism emerged early in the 20th century and became a major force in American psychology by mid-century. Based on the idea that behaviors can be measured, modelled, manipulated, and changed, early behaviorists rejected any reference to the mind, and viewed overt and observable behavior as the proper subject matter of psychology. Strict behaviorists believed that all behaviors are the result of experience. The early patriarchs of behavioral psychology were predominantly physiologists and neurologists. Sometimes referred to as the father of classical conditioning, Ivan Pavlov (1849-1936) was a physiologist whose most famous research studied how manipulating the environment could influence the digestive processes (in this case salivation) of dogs. Next in the chronological line of behavioral researchers would be Edward Thorndike (1874-1949). Considered by some to be the father of educational psychology, Thorndike’s study of learning in cats led him to formulate his theory of “Law and Effect.”  This theory states: “Responses that produce a satisfying effect in a particular situation become more likely to occur again in that situation, and responses that produce a discomforting effect become less likely to occur again in that situation.”  The two most renowned behaviorists were John B. Watson (1878-1958) and B.F. Skinner (1904-1990). Both worked predominantly with animals. Skinner developed a theory that was termed “Radical Behaviorism” with the tenant being that the concept of free will was simply an illusion, and that all human action was the direct result of conditioning. In 2002, Skinner was identified as the most eminent psychologist of the 20th century (Rev of Gen Psy. 6(2): 139-152)  

Behaviorism psychology show when giving a Dog a Treat

By the 1950’s, many engaged in the field of psychology saw the behaviorist view lacking. Other than the strict behaviorists, most psychologists held that primates were doing more than just reacting to what they were exposed. Pure behavioral learning theory, based on exposure and reinforcement, was seen as too limited and did not explain the great preponderance of behaviors exhibited by most higher primates and humans. There was clearly a form of cognitive mediation (covert brain activity) that influenced the nature of observed behaviors.  Psychologists observed that humans often continued to engage in behaviors long after they stopped being functional, and in fact, would continue engaging in behaviors even when they became harmful. As an example, someone who would compulsively wash their hands after having an aversive experience, often involving coming in to contact with what they perceived as a noxious substance, may continue to engage in obsessive handwashing long after the offending stimulus has dissipated. Further, this behavior would often generalize, that is, the individual would engage in this behavior when experiencing other forms of stress and discomfort. Similarly, someone who had experienced near starvation may engage in over-eating the first time they were provided nourishment. However, long after the negative experience, the individual might continue to engage in binging behavior even when there was an abundance of food readily available. From case studies such as these, it was obvious that covert mediating processes (e.g., the individuals’ thinking), were involved in the emergence and continuation of the observed behavior. Partly in response to the observed limitations of applying strictly behavioral methods in the remediation of psychological disorders, and a sense by many in the field that when it came to human’s interaction with their environment, there was a lot more going on than just the observable behavior, the 1960’s saw the rise of the field of Cognitive psychology.  

Cognitive Psychology

As a metaphor, think about the process of baking bread. One combines flour, water, yeast, sugar, heat, and time, and we end up with bread. But what is happening in the oven that we cannot observe? Obviously a lot!  Similarly, as humans make their way through the world, they are perceiving, transforming, organizing, storing, integrating, and recovering a great deal of information, and most of these processes are unobservable to the human eye. With this recognition, cognitive psychologists work is focused on getting a better understanding of what is happening between stimulus and response. Cognitive psychologists study all aspects of information processing, from perception to reaction. They study subliminal perception; what humans perceive below the threshold of awareness, reaction time; how quickly a response is elicited by different kinds and levels of stimulation/input, short and long-term memory, attention, self-perception, and language development. However, for the most part, cognitive psychology resides in the realm of research, measuring, quantifying, and inferring. While a great deal of data was and continues to be gathered regarding neurobiological functioning, the work of cognitive psychologists does not, as a rule, directly translate to psychotherapeutic intervention, but as with behaviorism, many of their findings have been applied and integrated into the practice of medicine, the field of education and of course psychology. 

To summarize the above, more than a half century after the advent of psychotherapy, an increasing number of mental health professionals held that there was little scientific evidence that psychoanalysis was producing wide-scale positive outcomes, and any efficacy that was realized occurred over very long periods of costly and intensive therapy.  Strict behaviorists, their research and related therapeutic interventions were seen as unethical.2 Moreover, the interventions were providing relief of limited duration, and when used exclusively, as having little utility in the treatment of many, if not most, psychological maladies. Cognitive psychology and its related research was successful in shedding light on covert psychological processes that clearly played a role in human behavior, but did not directly result in the advent of widely used therapeutic interventions. So out of the need for more effective, evidence-based, and time-sensitive interventions, the field of cognitive behavioral therapy evolved.  

1For the purpose of the following discussion, I am defining human behavior as “anything a person does.” This includes both internal processes, activities that cannot be seen by an outside observer, (e.g., thinking), and external processes that are observable to onlookers.  Further, some internal behaviors, specifically thoughts, can be observed by the person doing the thinking, and some thoughts can lay below the thinker’s immediate conscious awareness.  Finally, some behaviors are non-volitional, not under our control, and encompass both internal and external behaviors (e.g., thoughts, emotions, and reflexive and other biological processes).
2Much of the psychological community is of the view that much of behavioral research was, and in many cases remains, unethical and inhumane.  Animals were often subjected to aversive stimuli for the purpose of eliciting abnormal behavior, and these circumstances would be manipulated again and again to see just how mailable behavior could be. Human subjects were often exposed to physical and, very often, psychologically aversive experimental paradigms.

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