“Very little is needed to make a happy life; it is all within yourself, in your way of thinking.”Marcus Aurelius
In this blog, I continue my journey down the developmental history of cognitive-behavioral therapy. My purpose is to place current approaches in context and to help readers see how our understandings have changed over time. With this in mind, and to ensure readers get the most out of this series,, I highly encourage readers to read the 3 parts in succession. Cognitive-Behavioral Psychotherapies: Part 1 can be found here
In general, cognitive-behavioral therapies are a constellation of therapeutic approaches that hold in common the view that many psychological disorders arise from faulty cognitions and the corresponding adoption of maladaptive behaviors. They all approach treatment by utilizing both cognitive and behavioral methodologies. Additionally, while cognitive behavioral therapists believe behavior is, to some degree, influenced by genetic predispositions, they see human functioning as more malleable, and considerably less determined, than what is held by psychoanalytic and behavioral theories of human psychological functioning.
All cognitive-behavioral therapies take a constructivist view of psychological functioning. That is, while there are certainly external forces at work, their view is that we create our reality. Additionally, they hold that until clients are made aware of, and helped to change erroneous thinking and dysfunctional behaviors, no amount of exploration of past events will free them from their suffering. Importantly, they do not set out to blame clients for their disorders, but to validate their experience and empower them to change. Finally, all cognitive-behavioral therapies utilize techniques formulated by behaviorists. That is, they work to alter behavior not just by helping their clients become aware of their irrational beliefs and automatic thoughts, they also work to change their clients’ physical experience of their disorder. They do this by employing an array of behaviorist methodologies such as progressive muscle relaxation, breathing, visualization, exposure/desensitization, and intrinsic and extrinsic reward contingencies.
Rational Emotive Behavioral Therapy2 (REBT)
Albert Ellis was a pioneer in cognitive-behavioral therapy. His work with irrational thinking was foundational in the development of all cognitive-behavioral interventions. Ellis started practicing psychotherapy in 1943. From 1943 to 1947 Ellis practiced what he termed cognitive-behavior sex therapy, working with clients to overcome sexual as well as love and marital difficulties. During this work, Ellis noted that he could help his clients overcome their problems in just a few active and directive sessions. After this, Ellis trained in and then practiced psychoanalysis for six years, but finding it inefficient, he abandoned it in 1953. After another two years of exploring of many therapies,” Ellis embarked on practicing what he termed as a “more efficient form of psychotherapy,” which he would name Rational Emotive Therapy (RET), eventually renamed Rational Emotive Behavioral Therapy (REBT). Ellis held that people are basically “self-disturbing” by nature, and that our personal philosophy contained rigidly held beliefs that were the main source of emotional pain and dysfunctional behavior. His approach focused on changing the client’s self-defeating beliefs and commensurate dysfunctional behaviors by demonstrating their irrationality. Ellis viewed the client as engaging in a self-defeating dialogue that was predominated by should/shouldn’t and must/mustn’t statements, and termed this internal dialogue as “musturbation.” That is, rather than rationally appraising life events, clients would often resort to irrational expectations of how things should and shouldn’t or must and mustn’t be. In addition to coining the term “musturbation,” Ellis popularized such terms as “magnification,” “awfulization,” and “catastrophizing.” He viewed many of the psychological disorders assigned to patients not as illnesses, but as behaviors patients were choosing to engage in. So, when a client was diagnosed as depressed, he would state that the patient was “depressing,” that is, actively engaging in behaviors (thoughts and overt behaviors) that increased their experience of depression. Similarly, he would say that anxious clients add to their suffering by “anxietizing.”
Ellis’s main method of therapy was identifying what he called “irrational” beliefs and thoughts, actively pointing them out to his patients, and challenging these beliefs. He would often engage the client in a form of Socratic questioning to help them alter their “self-constructed distorted views of themselves, of others, and of the world.” He might also have a client visualize their worst-case scenario, a form of exposure therapy, the goal of which was to desensitize the clients from their caustic thoughts and fears. By pointing out “their dogmatic, absolutistic attitudes and dysfunctional feelings and behaviors,” Ellis hoped to subject clients to what he termed “greater sanity.” As with all psychotherapeutic interventions, Ellis’s goal was to help his clients “fulfill more of their human potential, to actualize themselves, and to enjoy themselves more fully.” As Ellis continued to expand on his theory of human behavior and psychological disturbance, he increasingly took the view that the irrational thinking, the fears and avoidant behaviors that people engage in, are not exclusively self-generated, but also a function of “biological tendencies” as well as social learning. As a result of these observations and shifts in his theoretical outlook, as practiced, REBT became less confrontational and more humanistically oriented, that is, softer, more compassionate, and unconditionally accepting.
Cognitive Behavior Therapy (CBT)
Cognitive Behavior Therapy (CBT), as developed by Aaron Beck, is a cognitive behavioral approach that has become synonymous with all cognitive-behavioral therapies. A psychiatrist, Aaron Beck graduated medical school in 1946, and like Albert Ellis, spent his early clinical career practicing psychoanalysis. In psychoanalysis, the therapist is very passive, and the patient is asked to speak about anything that comes to their mind (free association). In observing his patient’s free association, Beck noticed that clients’ statements were often composed of what he termed “distortions” in their thought process. Beck conjectured that these irrational, erroneous and often self-critical statements must be rooted in fixed negative ways of assessing themselves and the world around them, and that these tendencies greatly influenced their emotions, behaviors, and self-concept. Beck observed that depressed clients’ statements exhibited a preponderance of irrational fears, thoughts, and perceptions, and that these negative views created an automaticity in the way his clients perceived all that they experienced. These observations led Beck to view depression not as a mood disorder, but as a cognitive disorder, a disorder in thinking. In response, Beck devised Cognitive Therapy (CT), eventually to be named Cognitive-Behavioral Therapy (CBT).
Like Ellis’s REBT, Beck’s CBT questions the validity of clients’ thinking, but focuses more on the cognitive distortions, (e.g. “I know I’m going to fail this test”), than on underlying rigidly held beliefs/absolutist thinking (e.g., “I must not fail this test”). As an example, a client may present with anxiety and depression, two disorders that are often seen to co-occur. An REBT therapist might examine the client’s belief that they “can’t,” “shouldn’t”, “mustn’t” experience anxiety and the notion that this rigidly held irrational belief is underlying their depression. A CBT therapist will be more likely to explore the actual content of the client’s thoughts, e.g., “I’m such a loser.” “I’m always anxious and that’s why nobody likes me.” The CBT therapist might suggest that these thoughts are not accurate (disputation), and then work on providing alternative, affirmative thoughts for the client to consider. They might also work with relaxation techniques to help with their client’s anxiety, and create an action plan to help them identify these thoughts outside of therapy, and assist them in taking positive behavioral steps in opposition to their negative thoughts.
Like the name changes suggest (RET to REBT and CT to CBT), cognitive-behavioral therapies continue to change and evolve. They are very eclectic and adaptive therapies with a great many tools available to practitioners. Since the inception of REBT and CBT, psychology has seen the creation and popularization of what are often referred to as a third generation of cognitive-behavioral therapies which integrate mindfulness and other techniques rooted in Eastern, Hellenistic (Stoicism) and Existential philosophy and thought, which is the topic in part 3 of this series of blogs.
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).
2All quotes attributed to Ellis where sourced from his publication: “Overcoming Destructive Beliefs, Feelings and Behaviors”, Ellis, Albert, Prometheus Books, 2001