CBT & Cultural Groups Discussion

Assignment description Please comment on the applicability of CBT with different cultural groups. You may refer to oneor more of the articles assigned for this week. Lastly, reply to two of your peers’ discussion
boards.
Readings – (will be attached as pdf)
1.
David, D. (2007). Quo Vadis CBT? Transcultural perspectives on the past, present, and future of CBT:
Interviews with the current leadership in CBT. Journal of Cognitive and Behavioral Psychotherapies, 7, 2,
171-217.
2.
Messer, S.B. & Kaslow, N.J. (2020). Essential psychotherapies: Theory and practice. Ch. 6 , Third Wave
Cognitive-Behaviorally Based Therapies
3.
Shen, E.K. & Alden, L.E., Sochting, I. & Tsang, P. (2006). Clinical observations of a Cantonese
cognitive-behavioral treatment program for Chinese immigrants. Psychotherapy: Theory, Research,
Practice, Training. 43(4), 518-530 (available online).
ADDITIONALLY – Can also use another relevant article/scholarly journal ALONG with on of the readings
above.
Notes – No plagiarism. In-text citations or references of reading and article. Concise response
(THIS IS A DISCUSSION BOARD)
Discussion Boards to reply to (can be 2-3 sentences) (response to peer’s discussion board post)
Discussion Post #1 – I am still unconvinced by CBT, but also feel like the practical approaches that the
readings highlighted, particularly for differing cultures, don’t provide useful tools that I see as being helpful
therapuetic interventions. I’m particularly frustruated by the Tempel (2008) article about the use of CBT for
single mothers who phsyically abuse their children. Although obviously I completely agree that the most
pressing concern is to stop the mother from beating her child, the absolute lack of structural analysis in
the article and that effect on the dynamic felt alarming. Structural and financial stressors or a past history
of abuse can be triggers for child abuse, anger, and aggression, and although a topic that requires
mandated reporting and careful, astute attention for the safety and long-term care of the child, the lack of
an analysis for an external or internal root of the problem, feels like its just going to cause that aggression
from the mother to be taken out in a different way. I see the efficacy from a very short-term perspective,
but in no way could I imagine that CBT on its own would suffice in shifting this dynamic in the long-term.
Discussion Post #2 Messer and Kaslow note on multiple occasions how CBT is seemingly not designed for individuals of
diverse cultural backgrounds. We don’t know how effective it really is for these individuals. “As is the
case with other behavioral health treatments, evidence is still limited regarding the effectiveness of
third-wave CBTs in understudied populations, such as ethnic minorities and sexual minorities in the
United States.”
Though third-wave CBT is positioned as being somewhat more culturally attuned from the
practitioners’ perspective. The authors also note that there have been many instances of potential
bias within the practice. While a key component of CBT is an agreed upon treatment plan and goals,
which could potentially incorporate the client’s culture, they also note that this agreement may
involve “letting go of his or her culturally supported problem-solving strategies for difficult private
events and a willingness to pursue psychological openness and acceptance as an alternative.”
This is not to say that it could never work for these individuals, however, more research and
development needs to be done to work with various cultures beyond assuming cultural competence
on the part of the practitioner.
RESPONSE DOES NOT HAVE TO INCLUDE THE POSTS ABOVE, you can respond with #1 &
#2
Clinical Forum Section
Journal of Cognitive and Behavioral Psychotherapies,
Vol. 7, No. 2, September 2007, 171-217.
QUO VADIS CBT?
TRANS-CULTURAL PERSPECTIVES ON THE PAST,
PRESENT, AND FUTURE OF COGNITIVEBEHAVIORAL THERAPIES: INTERVIEWS WITH
THE CURRENT LEADERSHIP IN COGNITIVEBEHAVIORAL THERAPIES
Daniel DAVID*
Babes-Bolyai University, Cluj-Napoca, Romania
Abstract
Cognitive behavioral therapy (CBT) has emerged from the work of Dr.
Aaron T. Beck and Dr. Albert Ellis. However, it has been extended well
beyond the borders of the research groups of these two founders, all over
the world, in Asia, Europe, South America, and the USA. The question,
taking into account the unprecedented expansion of cognitive-behavioral
therapy, is whether current cognitive-behavioral therapy is still a coherent
and homogenous approach. Therefore, we have interviewed the major
representatives (presidents and/or board members) of major cognitivebehavioral psychotherapy organizations in Asia, Europe, South America,
and the USA. Interestingly, both at a theoretical and practical level, the
perspectives are quite coherent suggesting that the cognitive-behavioral
approach is a robust approach with cultural adaptations, which do not affect
the main architecture of the theory and practice of CBT.
Key words: cognitive-behavioral psychotherapy, theory, practice, analysis .
INTRODUCTION
Cognitive behavioral therapy has emerged from the work of Dr. Aaron
T. Beck and Dr. Albert Ellis. However, it has been extended well beyond the
borders of the research groups of these two founders, all over the world, in
*
Correspondence concerning this article should be addressed to Dr. Daniel David
No. 37 Republicii St., 400015, Cluj-Napoca, Romania;
Email: danieldavid@psychology.ro
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Asia, Europe, South America, and the USA. The question, taking into account
the unprecedented expansion of cognitive-behavioral therapy, is whether
current cognitive-behavioral therapy is still a coherent and homogenous
approach. Therefore, we have interviewed the major representatives
(presidents and/or board members) of major cognitive-behavioral
psychotherapy organizations in Asia, Europe, South America, and the USA.
The other organizations, not included in this analysis, have a cultural
background and a scientific approach that fits one of these major
organizations. The questions of the interviews were carefully selected to cover
important past, current, and future theoretical and practical issues, of whose
clarification is fundamental for the field of cognitive-behavioral therapies.
I. European Association of Behavioral and Cognitive Therapies
?? Jan van den Bout is professor of clinical psychology and Head of the
Department of Clinical and Health Psychology of Utrecht University,
the Netherlands. From 1997-2005 he was president of the Dutch
Association for Behavior and Cognitive Therapy, and is, since 2003,
President of the European Association for Behavioral and Cognitive
Therapies (EABCT). His research focuses mainly on complicated grief
and psychological trauma.
Q 1. How would you briefly define CBT and who do you consider to be the
major founders/originators of CBT?
A.
CBT is a branch of psychotherapy, which heavily lends on the attitude,
theories, principles and findings of academic psychology. CBT is a mixture of
behavior therapy (=BT) and cognitive therapy (=CT). For behavior therapy the
central learning principles are classical conditioning (Pavlov) and operant
conditioning (Thorndike; Skinner). Early pioneers who made important
contributions to behavior therapy include Mowrer, Wolpe, and Eysenck. The
‘founding fathers’ of cognitive therapy are Ellis and Beck.
2. As you know, there are many schools of CBT. What do you think are the
core common assumptions of these various schools? Is it correct to talk about
“various schools of CBT” or it would be better to reframe this as “various
strategies/theories/models part of a coherent CBT paradigm”?
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BT is grounded in experimental psychology, especially learning
theory. Learning principles (especially classical and operant conditioning),
first discovered and tested with animals, were the basis for the development of
efficient therapeutic procedures for humans. The relation between CT and
academic psychology is more difficult to define. Central for CT are
information-processing models, in which strong emphasis is laid on the
process of meaning making.
Whether there is one or there are two or many CBT
models/paradigms, it depends – as always – on how you look at it. When one
looks at the field of psychotherapy as a whole, then one is amazed about the
very diverse strategies/theories/models that exist. In fact these interventionstrategies are so different and sometimes weird that one can imagine that an
outsider would comment: ‘How could this all work and what a strange
profession is this’? Looking from that very broad perspective, CBT is a really
coherent paradigm. However, when one looks at the CBT-field properly, then
it is evident that rather big differences exist between BT and CT-approaches.
And when one takes an even more narrow view: even within the CT-field,
there are basic differences between the models of Aaron Beck and Albert
Ellis. However, it could well be – and this even applies for the field of
psychotherapy as a whole – that in terms of what therapists in fact do, the
differences may be less significant. For example, there are authorized
videotapes in which Beck shows therapeutic interventions that only Ellis
would execute, according to their writings, and vice versa.
3. What are the typical and specific aspects of the CBT clinical diagnosis?
How is it related to the evidence-based assessment movement?
Since a decade or more, the field of psychiatry and also clinical
psychology is highly influenced by psychiatric nomenclature, especially by
the DSM classification. This system is is sometimes said to be evidencebased, but this is true only to a certain extent, and the system has major flaw
backs. The main advantage of a classification system like the DSM is that
researchers and clinicians now more or less know what other professionals
mean by terms like Schizophrenia and Panic Disorder, and this, of course, is a
good thing. However, this sort of classification-thinking is in my view in
contradiction with one of the main tenets of BT, namely that problematic
behaviors and emotions are controlled by antecedent and consequent stimuli.
Thus identical problematic behaviors and emotions may well be functionally
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quite different; therefore it follows that an analysis of the individual client
remains in my view always necessary.
4. How do you see the role of the cognitive conceptualization/mediation
currently in CBT, and how is it related to therapeutic myths? Do we currently
have strong enough theories to conceptualize pathology or more research is
needed to develop new theories? What is your opinion on theoretical
eclecticism?
Our knowledge on the etiology of psychopathology is still scarce. In
the last years new and illuminating disorder-specific theories have been
presented. A good example is PTSS: theories with rather specific predictions
on the etiology and continuation of PTSS have among others been developed
by Brewin, Dalgleish, Ehlers, and Clarke. Although some of their predictions
have been tested, other predictions are still in need of empirical verification. In
the meantime clinicians have to work with their clients. Cognitive Case
Conceptualization seems to me a good clinical method to make a tailored
inventory of (the origin of) a client’s problems.
5. What is your opinion of the relationship among irrational beliefs, core
beliefs, and automatic thoughts? Do you think that rigid thinking
(demandigness) is one of the core mechanisms involved in psychopathology?
How about the role of the (cognitive?) unconscious in CBT?
First of all, there is no big need to quarrel about the exact differences
between sorts of beliefs. Beck made a pragmatic division between automatic
thoughts, intermediate beliefs and core beliefs, which perhaps is a handsome
division, although I note that it is possible that a client spontaneously utters an
automatic thought which may be a core belief. More important is, I think, that
it is the task and expertise of a cognitive therapist to go ‘deeper’ in the clients
cognitive system than (s)he is aware of. In therapy clients should experience
something new, be it with respect to their thoughts/beliefs or with respect to
their emotions. Remember that in psychotherapy-research it has been
consistently found that perceived ‘novelty’ is an important predictor of
positive therapeutic outcome.
Rigid thinking, frequently leading to demandingness, is indeed a major
‘pathway’ to all sorts of psychopathology. At the same time, demandingness is
a rather abstract term, and thus: showing clients that they are demanding all
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sorts of things, might well be a far too abstract intervention. More fruitful is in
my experience to try to unravel what is behind what is said by a client, to
probe what makes a client demanding something, for example: what makes it
that a female client becomes very angry towards her male partner when that
partner chooses to have a nice evening with his friends. One could of course
say that she is demanding something, but it would be more relevant to try to
ascertain what is behind that demandingness, for example, the thought that she
is not so important for her partner (probably leading to anxious or depressive
feelings) or thoughts like ‘in fact I am a worthless person’ (probably leading
to depressive feelings).
About the unconscious or preconscious: these terms were more or less
forbidden within CBT during the past years, probably because the terms have
a strong psychoanalytic connotation. But remember: both Ellis and Beck were
trained in psychoanalysis and practiced this psychotherapeutic method for
years. And although they later heavily rejected psychoanalysis, in their
theorizing, the legacy of Freudian thinking is quite clear. For example: when
Beck speaks of automatic thoughts which may arise from core beliefs which
the client not yet realizes himself, he in fact referring to unconscious or
preconscious beliefs. In a similar vein, Ellis has extensively written on such
preconscious beliefs. And even learning theorists were and are frequently
referring to such processes, although their terminology is quite different.
6. What is the role of the therapeutic alliance in current CBT? What is your
view on the role of transference and counter-transference in CBT?
The therapeutic alliance is rather important in CBT, although this is
seldom acknowledged. Skills to enhance the therapeutic alliance are a
prerequisite for most therapies. Remember that when BT and CT arose in the
fifties and sixties of the last century, the early BT- and CT-therapists were
nearly all trained clinic ians and thus knew about therapeutic alliance or
broader: they had already acquired essential therapeutic skills like empathy
and they knew the importance of (counter-)transference. Nowadays it happens
that novices have never heard of these phenomena. So I heavily plead that
within a CBT-curriculum there should be thorough training in these important
aspects of the client-therapist relationship.
These issues are still more important in the case of Axis-II problems.
This is quite understandable because the very essence of almost all Axis-II
problems is a very problematic way of relating to others. It is good to see that
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recently CT-therapists (such as Leahy) are giving more attention to these
matters.
7. What is the state of techniques in CBT and how do you see them in relation
with therapeutic rituals? Do we have powerful enough techniques to change
the etiopathogenic mechanisms once identified, or we still need research to
invent new techniques? What is your opinion on technical eclecticism?
‘Therapeutic rituals’ refer to – I suppose – the importance of common
factors. As I just said, I do think that these common or non-specific factors are
quite important, as most meta-analyses on the effectiveness of psychotherapy
show (although quite a lot of CBT-experts tend to discard these findings). I
stress to our CBT-colleagues not to neglect these matters. Effective therapists
should have superb non-specific skills (i.e. skills on the client-therapist
relationship) and superb specific skills (i.e. skills on influencing the specific
disorder). CBT research on these ‘disorder-specific’ mechanisms has been
very successful resulting in more efficient and time-limited procedures. In the
last decade even very problematic disorders like borderline-personality
disorder have been found to profit of CBT-interventions.
It should be stressed that almost all of these CBT-successes could be
accomplished by careful listening to the clients, building tentative theories on
the basis of these anecdotic data and testing these tentative theories, and
subsequently developing and testing CBT-interventions. This is the golden
way and also in the end, the most efficient way.
Technical eclecticism (in the sense of using whatever accidentally
seems to work) has its limits. So, the task of any CBT-professional is to
describe and try to fully understand the complaints (that is: to understand the
processes that give rise to these complaints, and fully understanding these
processes is quite dependent on the therapeutic skills of the therapist,
especially listening skills) and then try to intervene in these processes. And
thus: technical eclecticism is by definition a-theoretical and will not lead to
real understanding of the client problems.
8. How do you see the distinction among feeling better, getting better, and
staying better in CBT, in relationship to the therapeutic strategy?
That clients feel better in or during therapy sessions is not always a
good thing. For example, when a client is satisfied with himself because he
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has the idea (rightly or wrongly) that his therapist likes him, he may definitely
feel better, but is not getting better (because his self-evaluation is still
dependent on the evaluations by another person). Clinicians should be very
alert on this, also towards themselves, because they themselves of course are
also sensitive to these processes.
Getting better should result in staying better, and that normally means
hard work: CBT is not a miracle therapy. As ourselves, clients do not always
like hard work. In my experience, especially novice therapists are frequently
too soft in this matter. When clients say that is too hard or too much work,
they sympathize with them instead of asking them whether the fact that
something is difficult, is enough reason not to do it. ‘No gain without pain’, as
Albert Ellis used to say.
9. Can we talk about several waves of CBT? Which are these and how do you
see their interrelations? Is it a cumulative development or not?
Yes, there surely are different waves within CBT. As I already said,
the major waves are of course Behavior Therapy and Cognitive Therapy, as is
also exemplified in the name of the European umbrella association: ‘European
Association for Behavioral and Cognitive Therapies’ (=EABCT). Note that in
this name even the plural is used, because there are more than one behavioral
therapies and cognitive therapies. The integration between these behavioral
and cognitive approaches is in my opinion nowadays more a promise than an
accomplishment. There is much to gain there in terms of coming to a more
integrated mutual framework, although some seem satisfied with the current
level of integration. For example, the widely acclaimed and frequently used
and reprinted book of Hawton et al. (‘Cognitive Behavior Therapy for
Psychiatric Problems’) is without doubt an excellent book on CBTapproaches
for certain disorders, but the theoretical integration of behavioral and
cognitive approaches remains rather obscure in that book.
Some 5 years ago some CBT theorists and clinicians have proclaimed
a ‘third wave’ within CBT, but in my opinion it is too early to already speak
of such a ‘third wave’, especially because the differences between this
proclaimed new wave and the other two waves are –again in my opinion- not
yet articulated enough.
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10. How do you see the integration of cognitive and behavioral principles
(within theories and techniques) in present CBT? Is it real or it is just a cohabitation based on the common evidence-based background?
This is a difficult matter, let me give an illustration. Not everyone is in
agreement with the name ‘European Association of Behavioral and Cognitive
Therapies’, although the discussion about it is not so vehement anymore as it
was some 10 years ago. There are proponents of BT who in fact claim that the
addition ‘Cognitive Therapies’ (earlier the EABCT was called: EABT) is a
mistake, because all psychotherapy should be based on empirically-proven
principles of learning (classical and operant conditioning) and because
cognitive techniques are only a small part of the therapeutic package of
behavior therapists. My opinion is different: the cognitive therapies of both
Beck and Ellis are fully developed psychotherapies with their own
scientifically based theories and derived therapeutic techniques. And also: in
the major theoretical writings of both Beck and Ellis the contribution of and
the emphasis on learning principles is neglectable. So BT and CT are different
waves, which are in need of interrelation and further integration. Experts
disagree about the extent to which this integration has taken place. Some are
of the opinion that integration has grown to such an extent that one may speak
now of cognitive-behavioral therapy (=CBT). In fact the phrase CBT has
become very popular nowadays. I must confess I still have some reservation
with respect to the term CBT. It seems these days that everyone practices
CBT. In my own country (the Netherlands) hardly anyone calls himself ‘a
behavior therapist’ nowadays; all have become ‘CBT-therapists’. And thus:
the term CBT is, for me, becoming more or less meaningless.
11. How do you see the relationship between cognitive science and CBT?
There is much to gain there and I expect a lot of that development.
Cognitive (neuro)science is flourishing nowadays and the findings of that
booming branch of science will prove very relevant for the practice of CBT.
12. How do you see the role of CBT (a) in the effort of psychotherapy
integration and (b) in the evidence-based movement in psychotherapy?
Proponents of a every form of psychotherapy are of the opinion
(although they never say this so loudly) that their form of psychotherapy is the
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best, and I am not an exception to that rule. CBT is a very good candidate for
becoming the ideal ‘integrated’ psychotherapy for several reasons. First of all,
it is heavily rooted in science (in terms of orienting itself on and starting from
‘hard’ psychological science as well as being evidence-based in terms of
leading to lesser mental complaints/disorders). In addition, competent and
well-trained CBT practitioners make use of the ‘therapeutic jewels’ of other
psychotherapy branches, such as the emphasis on listening skills as developed
by our Rogerian or client-centered colleagues, and the notion of preconscious
or unconscious as first suggested by the psychoanalysts.
The answer to question 11, makes my point of view on evidence-based
quite clear.
13. Both Aaron T. Beck and Albert Ellis are living icons who keep the CBT
community close and in unity. How do you see CBT post Beck and Ellis?
Both Beck and Ellis have had an enormous influence on the
development of Cognitive Therapy, in fact they have created this now
dominant branch of psychotherapy. However, it is quite amazing how
differently these founding fathers are nowadays appreciated and honored by
the CBT-community: Beck is indeed a living icon and is honored very
frequently, while Ellis’ contribution to CT is far less acknowledged, which is
in my opinion not correct and not fair. Of course there are reasons for this
state of affairs (for example, Beck has always worked in an academic setting
and Ellis not; Beck is a more ‘polite’ and ‘acceptable’ person than Ellis), but
personally I am of the opinion that Ellis’ contributions to CT are equally
fundamental or more so than Beck’s contributions.
Both Beck and Ellis are very old now, but are both quite active still in
the field. CT indeed seems to be a very healthy endeavor, but even they are
mortal. Their intellectual inheritance is so immense and firmly grounded that I
do think that the field will not alter very much when they have passed away.
14. How do you see CBT in the next 25 years? What is the path we should
follow? What are the main dangers for the future of CBT? What is wrong now
in CBT?
The prospects for CBT look very good. It already is the evidencebased intervention for almost all mental disorders and the scope of its
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effectiveness for all sorts of disorders (for example, Axis-II disorders like
borderline personality disorder) is still growing. In terms of therapeutic
content I expect that the influence of non-Western philosophies like Buddhism
will be remarkable in the coming years. Mindfulness based cognitive therapy,
which in essence is a form of Buddhist practice, is a first recent example, but I
think that the Buddhist insights on the ‘ego’ will have an even bigger
influence on current CBT practices.
That CBT is the evidence-based intervention for almost all mental
disorders is of course known to CBT-therapists, but others (such as the
government or health insurance companies) are frequently not aware of this
state of affairs. We as CBT therapists are not very good in ‘selling our
products’; we simply think that ‘good products sell themselves’ and we are
wrong. Psychoanalysts are much more smarter in this. So we have a lot to do
in the outside world, especially in southern Europe where CBT still is not
widely known.
As a main danger I see the current trend in educational settings on
acquiring CBT-skills primarily by means of reading a protocol or a book
consisting of manuals. A CBT-therapist should acquire all sorts of skills
(general skills, such as listening skills or knowing how to handle
countertransference phenomena; CBT-skills, such as practicing flooding or
Socratic dialogue) and these skills should be taught and learned, which takes
time and should be extensively monitored. Nowadays the trend seems to be
that curricula are becoming shorter and I am afraid that novices will not get
enough training. Let me make a comparison with becoming a butcher: you
cannot learn that profession by only reading a book. And also: the final
examination for becoming a licensed butcher is that you show your skills
while slaughtering a pig or a cow. In a similar vein, the final examination for
becoming a licensed CBT-therapist should be showing your skills on a client
(for example, by means of a video-session), not just writing a report on your
therapeutical activities.
15. What are the main plans of your organization regarding CBT?
The most important plan can be derived from what I just said: the
emphasis of the EABCT is on developing and implementing training standards
for all 40 associations (out of 28 European countries) of which the EABCT is
the umbrella association. Ideally a CBT therapist from Estonia should have
comparable CBT skills with a CBT therapist from Romania or the
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Netherlands. Such an endeavor is not a simple one. To mention only two
problems: the academic disciplines (such as clinical psychology, psychiatry)
on which the registration of being a licensed CBT therapist is superimposed
differ greatly among European countries. And in some countries, such the
United Kingdom, nurses may become fully licensed CBT therapists while in
most other countries this is not allowed.
CBT has the potential of becoming the dominant form of
psychotherapy in Europe. EABCT tries to take the lead in this development,
and strives to become the leading psychotherapy organization in Europe.
Recently the EABCT has become an official legal organization, which makes
it possible to be an official partner in projects and developments within the
European Union.
II. Association for Behavioral and Cognitive Therapies & Albert Ellis
Institute, USA
?? Raymond DiGiuseppe is presently professor and Chair of the
Psychology
Department
at
St.
John’s
University,
USA.
Since 1980, Dr. DiGiuseppe also served as a Director of Professional
Education of the Albert Ellis Institute. He has trained hundreds of
therapists in REBT and CBT. He received the Jack Krasner early
career contribution award from APA’s Division of Psychotherapy and
has been elected a fellow of the American Psychological Association’s
divisions of Psychotherapy, Clinical, School and Family Psychology,
and president of the Association for Behavioral and Cognitive
Therapies.
Q 1. How would you briefly define CBT and who do you consider to be the
major founders/originators of CBT?
A
Humans behave, think, and feel almost simultaneously. CBT
interventions attempt to reduce human suffering and promote well being by
directly changing the way people behave, think, and feel. Sometimes we can
reinforce people to behave in new ways; however, most of the times we do not
have direct control over the reinforces. To convince people to behave and feel
differently therapists usually have to influence the way people think. The
cognitive element in CBT influences the way people construe, or think about
their world, or how they process information. Almost always therapists use
both behavioral and cognitive interventions.
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The title CBT poorly reflects the emotional side of human experience.
The primary therapy I have practiced and promoted over the years RationalEmotive Behavior Therapy does include the feeling side of human experience
in its title. However, most CBT therapists utilize affective experiences to help
people change.
In the past century Al Ellis, Tim Beck, Mike Mahoney, Marvin
Goldfried, and many others started the trend in CBT. However, CBT is a
definite our growth of behavior therapy. The “cognitive” roots of CBT go
back to the earliest Greek, Roman, and Asian philosophers. CBT therapists
and researchers have applied and empirically tested the value of many early
philosophical ideas concerning how to live a better life.
2. As you know, there are many schools of CBT. What do you think are the
core common assumptions of these various schools? Is it correct to talk about
“various schools of CBT” or it would be better to reframe this as “various
strategies/theories/models part of a coherent CBT paradigm”?
I think the development of various schools of CBT presents the
greatest challenge to our field. Recently, I came across an interesting message
someone posted on the list server of the Association for Behavioral and
Cognitive Therapies. This message questioned how a particular school of
CBT would conceptualize the treatment of anger. One prominent psychologist
advised the sender of that message to continue the discussion on a separate list
server devoted to that particular theoretical perspective. I did not get to see the
rest of the discussion and missed out. And only people with a limited
theoretical perspective entered that discussion. We have had a proliferation of
CBT models including ACT, DBT, CT, REBT and several others. Although I
am primarily associated with the REBT “School,” I read and follow the
developments in all these areas and borrow their ideas and clinical strategies. I
think a broad dialogue between people with diverse ideas makes for a richer
theory and more effect clinical practice. However, today we have some large
umbrella CBT organization and many smaller organizations and conferences.
If we look back, this type of fragmentation occurred in
psychoanalysis. People who had different ideas from Freud went off and
created their schools of therapy with separate training, journals, and
conferences. I think this had a negative impact on that field. Science does not
work by having people with different ideas go off and talk to themselves. That
stifles criticism. We all need to present our ideas and the support for them in
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the open market. As Karl Popper pointed out, falsifiablity is the hallmark of a
true science. One is less likely to falsify one’s ideas if he or she speaks to a
like-minded audience. So, I think we are better off reframing this as various
strategies/theories/ models rather than as different schools. Fragmentation
could have a negative impact on CBT as it did on Psychoanalysis.
I think people form different school of thought in any academic area
because organizations or social groups reach a critical size of members. At
some point a group is too large for people to feel a sense of belonging or
commitment to the group. Some people then branch off and form their own
communities. This happens in religions, political parties, and all other
academic disciplines. It is probably the human imperative that pushed our
species out of African to colonize the world. So, this aspect of human nature
has been good for the human species. However, it may be a bad thing for
science. I think CBT therapists should talk to psychotherapist and
psychologist who have radically different ideas. This will help us test our
ideas and enrich what we do.
The various CBT models share the idea that humans learn how to cope
with the world and the people in it. Our brain helps us construe the world so
that we can cope better. However, the mechanisms of learning and construing
about the world do not always work well. Helping people to understand those
errors and fixing them is the business of all the models of CBT.
3. What are the typical and specific aspects of the CBT clinical diagnosis?
How is it related to the evidence-based assessment movement?
The movement toward evidence–based treatments has been focused
primarily by research funded by the US National Institute for Health. This
organization is a health/medical organization. As such, it exists to understand
the identification of illnesses and diseases. Thus, the research it funds aims at
understanding diagnostic conditions. However, a clear connection may fail to
exist between diagnostic conditions and functional dynamics that cause people
to suffer and that prevent their growth. Within any diagnostic group of
patients, each person’s problems many result from different types of
behavioral excesses and deficits or different types of cognitive dysfunctions
and cognitive deficits. The original behavior therapists resisted diagnosis and
instead focused on functional relationships. This is still good advice.
Functional relationships between stimuli, thoughts, feelings and behaviors are
the keys to understanding the patients, not the diagnosis. Our Evidence-based
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focus requires big money to run random clinical trial. To do this we need to
focus on grants; and grants seem to be attached to diagnoses. Thus, we have
lost much of original focus on studying the functional relationships with in the
person.
I think part of the problem with assessment in CBT reflects back to
your last questions on the development of different models of CBT. Each
model focuses on a specific type of cognition that it postulates as the mediator
of disturbed behavior and affect. These mediators are hypothetical constructs
whether they are automatic thoughts, self-statements, underlying schema,
social problem solving deficits, or irrational beliefs. Most CBT therapists
focus on one or a few of these types of cognitions when they write about
therapy or design research. The proliferation of ideas in CBT has lead to a
narrow focus on what cognitions to assess. As a result we fail to see if any
relationships exist between these various cognitions or to assessment all in
clients. Perhaps could learn how these different cognitive constructs relate
with one another. Perhaps different cognitive constructs mediate disturbance
in different patients. But focusing on one model prevents that focus.
4. How do you see the role of the cognitive conceptualization/mediation
currently in CBT, and how is it related to therapeutic myths? Do we currently
have strong enough theories to conceptualize pathology or more research is
needed to develop new theories? What is your opinion on theoretical
eclecticism?
Cognition was considered a black box in psychology for so many
decades and we only recently have developed some ideas about how people
think. We have very weak theories concerning how cognition mediates
emotional and behavioral disturbance. AS I mentioned above, most CBT
models focus on a specific type of dysfunctional cognition that clinical
practice and research in the model has linked to psychopathology. They focus
less on the learning processes that led to the development of those cognitions.
Most other CBT models have good research support that the cognitions they
espouse are related to psychopathology, but have less good research on how
people learn these cognitions. So I would say we need more and better
theories about how people learn to become disturbed. Such theories will lead
to better research and more effective interventions.
The last part of this question focuses on theoretical eclecticism.
Thomas Kuhn in his classic book The Structure of Scientific Revaluations
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described a stage in the development of science, the pre-paradigm stage,
where no major theory dominated the science. Some people say that he had
psychology in mind when he described the pre-paradigm stage of science.
Psychology in general and psychopathology and psychotherapy in particular is
still in a pre-paradigm stage. So relying too heavily on any particular theory
will cause problems. So while I think primarily in a CBT theory, there are lots
of competing theories. We may have too modify some aspects of our CBT
model until we have a more unified science.
5. What is your opinion of the relationship among irrational beliefs, core
beliefs, and automatic thoughts? Do you think that rigid thinking
(demandigness) is one of the core mechanisms involved in psychopathology?
How about the role of the (cognitive?) unconscious in CBT?
I think Beck and Ellis hold similar models. What Beck calls, automatic
thoughts, and what Ellis calls inferences, are generated by non conscious,
schematic type of cognition. Beck would say that schemas generate the
automatic thoughts; and Ellis would say that irrational beliefs generate them.
So, the question remains what is the relationship between schemas and
irrational believes. Schemas as they are used in Beck’s cognitive therapy
model are constructions of the world. Irrational beliefs are somewhat different.
They always imply a construction of the world, as do schemas. However,
irrational beliefs are schemas of the world about things that the person highly
desires to be or to have. So Ellis has reserved his concept to focus on the
constructions of the world about things or events that they have a strong
motive attraction. Both models believe that changing these schemas or
irrational beliefs will reduce the production of automatic thoughts/inferences.
Also, challenging automatic thoughts/inferences will undermine the support
for a schema. Therefore, changing them will ultimately lead to changing the
schemas or irrational beliefs.
Ellis has long maintained that the concept of demandingness
represents the core or foundation of psychopathology. Although
demandingness definitely has shown to correlate with psychopathology, it has
been difficult to prove Ellis theory. REBT theory would say that schemas are
constructions of the way the world is. Schemas only cause us problems when
they concern what we want to be true because they concern some events that
are associated with strong motives. Holding on to the schema when you have
evidence that it is wrong represents demandingness. It is similar to Piaget’s
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concept of assimilation. The person tries to make the schema fit the data rather
than revising the schema to fit the data.
Some of Ellis’ proposed irrational beliefs concern awfulizing,
frustration tolerance, and self or other denigration. These irrational beliefs can
also lead to emotional disturbance. The question is whether these other
irrational beliefs independently cause emotional disturbance or are associated
with demandingness. Thus, they lead to emotional upset because they mediate
the effect of demandingness or reflect demandingness in some way. I think
that awfulizing and frustration tolerance beliefs will eventually be shown to be
psychological derivatives of demandingness. Thus, “I want something, it must
exist, and it is awful when it does not exist.” The idea of global human worth I
think is different.
Ellis has said that demandingness leads to global evaluations of human
worth. So, the belief “I am a worthless person” can cause one to be disturbed.
But people usually make such global judgments of human worth because of
the failure to fit some standard. So, the actual irrational beliefs may be “I have
to make sense in this interview, or I am a worthless person.” People are
usually not aware of the first part of the sentence, and experience just the
worthless part. The core underlying schema in a cognitive therapy case
conceptualization might be “I need to be competent.” The irrational belief
reflects both the underlying schema, “I must be competent” and a factual
statement of the worth of the person if the standard is not met. So, you have an
irrational belief that reflects a demand and a factual extension about the
person’s worth.
So I think there are two types of irrational beliefs. Some demands lead
to derivative beliefs concerning the awfulness of the situation or the inability
to survive the frustration of not getting the demand met.
Most schemas and irrational beliefs are not in the stream of
consciousness. People do not come to therapy aware of these constructs. That
is why Beck started with the automatic thoughts. They are stream of
consciousness experiences. The key challenge in CBT is getting from the
stream of consciousness beliefs to the core beliefs. Whatever strategy one
uses, it is clear that CBT acts as if these beliefs are out of awareness.
However, they can be brought into awareness by a number of clinical
strategies. Although CBT would see that such unconscious beliefs and be
brought into awareness much easier than our psychoanalytic colleagues. I do
not like to use the term unconscious because that term has so much meaning in
psychoanalytic psychotherapy. I think CBT sees the nonconscious cognitions
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as easily being brought to consciousness. Also, becoming aware of the
nonconscious beliefs does not appear sufficient for changing them. The
rehearsal of new beliefs to replace them appears crucial. Although insight
alone can sometimes cause change, it is not enough.
6. What is the role of the therapeutic alliance in current CBT? What is your
view on the role of transference and counter-transference in CBT?
When I was a fellow co-leading a group with Al Ellis, I was amazed at
how dedicated his clients were to him. Yes, he was sometimes brutally direct
with them, but not often. Al structured this training experience so that the
fellows spend 90 minutes with him and the group. Then the trainee would
spend another 30 minutes with the group without Al. This time was designed
for reviewing and constructing homework assignments. Here is my big
confession. I often used this time to explore with the group their perceptions
of Al as a therapist, especially those with whom he had been most direct. I
recall many of them reporting that although Al was confrontive, they felt close
to him because he had their best interns at heart. They believed he was
dedicated to helping them change for their own good. I learned early that
relationship issues are crucial to effective therapy. Research on the therapeutic
alliance shows that it functions in all types of therapies. So how does CBT
differ from other therapies on this issue? Well maybe it does not. Perhaps we
get the same therapeutic alliance that other therapist do. Maybe we get a better
alliance because we, like Al, demonstrate our dedication to helping the client.
What is different is the role that is prescribed to the relations. Bruce
Wampold’s book “The great Psychotherapy debate” represents another view
of therapy. Wampold and Mike Lambert believe that the alliance and other
such variables account for as much of the variance in therapy outcome as do
empirically based interventions. Many psychotherapists hold this idea and
think that the interventions are less important than relationships. So they focus
on relationships with clients and think that techniques are less important.
Al Ellis’ early debate with Carl Rogers on this matter is still relevant
today. Rogers said that unconditional acceptance by the therapist was
necessary and sufficient for change. Al disagreed. However, he did not say
that the relationship was irrelevant. He said it was highly conducive to change
but was neither necessary nor sufficient. People could change without it, and
other things could produce change. But acceptance was highly valued. All of
the originators of CBT, Tim Beck, Marvin Goldfried, Mike Mahoney, and
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Don Meichenbaum displayed great warmth and acceptance toward their
clients. I am unsure how the idea got started that behavioral or cognitive
therapists do not value the therapeutic relationship. CBT researchers have
focused more on identifying the variance attributed to techniques and have
focused little attention on the variance in therapy outcome accounted for by
relationship issues. I think future CBT research needs to focus on both sets of
variables if they are to meet the challenging hypothesis posed by Wampold
and Lambert.
Part of the therapeutic relations concerns the clients’ feelings toward
the therapist and the therapists’ feelings to the clients. This is what the
psychoanalysts called transference and counter-transference. These issues did
not appear much in the early books on CBT. I think early CBT therapists were
reluctant to use the terms transference and counter-transference, since these
terms were associated with rather specific psychodynamic theoretical ideas.
They also were trying to present an alternative model of therapy and did not
focus on similarities. Any therapist who does not attend to the way a client
feels and reacts toward him or her does a great disservice to the client. We are
people in their lives and they will often respond to us as they would to other
people of similar stimulus characteristics. Part of one’s growth as a therapist
involves becoming aware of one’s biases and how they affect our therapy.
There is nothing in CBT theory that precludes these ideas from informing the
CBT practice.
7. What is the state of techniques in CBT and how do you see them in relation
with therapeutic rituals? Do we have powerful enough techniques to change
the etiopathogenic mechanisms once identified, or we still need research to
invent new techniques? What is your opinion on technical eclecticism?
By technique, I think you are asking me about the tasks that therapists
do. As a trainer, I am sometime concerned with the development of techniques
in therapists. Learning good technique is crucial to becoming a good therapist.
I like to make the distinction between technique and strategy. Technique is
what you do and strategy is how you conceptualize the client and the broad
interventions that flow from this. Therapists love to talk about strategy.
Focusing on the client is safer. After all, we know they have problems.
Focusing on technique means focusing on us. That is more threatening. In
REBT training, we purposefully teach therapists the techniques of identifying
As, Bs, and Cs and changing them. Some people leave the training with great
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technique but no strategic judgment. But I still think learning good techniques
is important, and eventually trainers need to make sure the therapist learns
both technique and strategic judgment. Therapists who learn a technique well
not only learn how to do a specific intervention. They learn the importance of
learning technique and hopefully learn to attend to their own skills so that they
can learn any technique well. Developing good technique requires self
awareness, openness to acknowledging errors, and acceptance of feedback.
Without these characteristics, therapists ossify.
Going from theory to technique requires a degree of specificity many
people cannot do. It is sometimes easier to remain abstract and not deduce the
specific therapeutic behaviors that follow from one’s theory or case
conceptualization. I like your reference to ritual in this question. I have
encountered many therapists who claim a CBT orientation and can talk about
the client’s thinking. Yet they cannot describe what types of thoughts they
think mediate the client’s problems and what specific cognitions they attempt
to change in the session. Also, therapists often focus on the ritualized
mannerisms of their favorite theoretician. However, a focus on technique
(what the therapist does) is a strength of CBT. Many new techniques can be
developed from all types of theories in psychology to make our therapies more
effective.
Arnold Lazarus has always been a model for me. He recognized that
many techniques that can lead to significant clinical change. Like Al Ellis,
Arnold rejected the idea that any techniques are necessary and sufficient for
change. Many different paths can lead to the same outcome. The technical
eclectic therapist develops a case conceptualization of clients and their
problems. She or he can imagine numerous ways to affect the mediating or
hypothetical constructs that she or he sees as maintaining the client’s
disturbance. Affect, emotional, imagery and behavioral techniques can all
influence the schema or learned confections that maintain disturbed behavior.
The context of the therapeutic tasks or assignments affects the connections
between the stimulus and the disturbed response. An intelligent and flexible
therapists use any type of task that changes the meaning. Technically eclectic
therapists focus more on the meaning or previous learning that maintain the
disturbance rather than techniques. I think this will result in more effect
therapy. However, the efficacy of technical eclecticism would be difficult to
test because it would hard to write a treatment manual that could be used in a
clinical trial study. I would suspect that more experience is needed to use
technical eclecticism. However, if we could write such a manual we would
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have a great advancement in therapy. Steve Hayes’ work on Acceptance and
Commitment Therapy seems the closest to technical eclecticism today. He
does not advocate specific techniques but an understanding of the contextual
relationships in which disturbed responses are embedded. Many other schools
of therapy focus more on techniques which may result in rigid adherence to
technique over understanding clients and their problems. It is harder for
people to understand and learn a system of therapy that focus on
understanding the client rather than techniques. However, I think it will pay
dividends down the line.
8. How do you see the distinction among feeling better, getting better, and
staying better in CBT, in relationship to the therapeutic strategy?
Feeling better reflects a change in the client’s emotion emotional state
and a change to more adaptive behavior. Clients can have a short term change
in their emotional state because they have had an external change in their life
situation. Also, they can successfully avoid the situation that triggers their
upset. Clients can also feel better because they have learned to dismiss the
possible occurrence of situations that are difficult or upsetting. For example,
clients who fear that their lover may leave them could convince themselves
that such events are unlikely. They can cognitively avoid the upsetting stimuli.
Using this strategy fails to teach a new response to the upsetting stimuli. Al
Ellis referred to this as feeling better without getting better. Such
improvements involve no change in their coping strategies, their core schema,
the meaning they attach to events, or the responses they make to difficult life
situations. So, it is possible for the client to feel better without any real change
at a deeper cognitive level. I dislike the term “deeper” because we do not
know if such change occurs deeper in the brain. But let’s say that no new
response has been learned to the stimuli that use to connect to their emotional
disturbance. When a client gets better, they have learned a new response or
developed a new set of meanings or changed their philosophy. They can
approach that previously elicited upset with new responses and new learning.
Therapists can easier help clients feel better by learning to dismiss the
likelihood that bad events could occur than they can produce real change.
The real proof of successful therapy is facing one’s fears, anger
triggers, or temptations. I treat many domestically violent men. I always
advise them to say in treatment until they become involved in a new romantic
relationship. They often believe they are cured quickly. Usually the courts
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forbid them to see their spouse and they are living alone; big surprise, they
have no anger problems. The test of therapy occurs if they can live with the
old or a new partner and not become angry and abusive when they do not get
their way. Developing a new philosophy and response to their partners’
assertions and desires is much more difficult.
The American humorist Mark Twain said that he had escaped many
catastrophes that never occurred. Anxious people do exaggerate the
probability that bad things will happen. Many people will try to help clients
see that they do over predict negative events. However, teaching them that
they could cope, even if the negative events occur, would produce a more
enduring, generalizable response to anxious triggers. This strategy will also
result in their making fewer negative predictions. Some CBT therapist would
say that this may be too difficult to do and creates a needlessly hard task for
the therapist and the client. I agree it is more difficult. However, I predict that
it will more enduring and lead to less relapse.
So, I agree with Ellis that it is best to help clients face the events that
have either triggered their disturbance in the past or face the possibility of
events that they think could happen.
9. Can we talk about several waves of CBT? Which are these and how do you
see their interrelations? Is it a cumulative development or not?
This question reminds me of the test of an evolutionary theory. Does
change occur gradually as Darwin suggested or in punctuated waves as Steve J
Gould proposed? Has there been a continuous, slow evolution of thought in
CBT with three separate species evolving from each other? I do not think so. I
think such questions distract us from the good ideas within each wave.
Many of the ideas in these success waves existed throughout behavior
therapy. The first issue of the official journal of the Association for the
Advancement of Behavior Therapy had an article by Tim Beck on Cognitive
Therapy. It would be decades before the name of the association would
change to the Association of Behavioral and Cognitive Therapies. But
cognitive interventions were acknowledged from the beginning. Also, Joe
Wolpe’s systematic desensitization was described as a form of conditioning
therapy. But he paired the relaxation response with images of the feared
stimuli. Who would not consider images a type of cognition? So cognition
was really present in the first wave even if people did not acknowledge it.
The same can be said of the third wave. Acceptance therapies are
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based on an operant learning view of human learning. However, two aspects
of the third wave have existed since the beginning of behavior therapy. First,
acceptance is not a new idea and was a central part of Ellis’ Rational Emotive
Therapy. Ellis did not claim to invent the idea of acceptance, but credits
numerous philosophers with the idea. Second, many therapists attempted to
use Skinners model of verbal learning to account for cognition. The third
wave does this better but people in the field have always struggled with this
issue.
However, the ideas in the third wave present advances to the field and
very interesting hypotheses for clinical interventions. Steve Hayes’ Relational
Frame Theory may provide the most rigorous model of how ideas come to
have meaning that lead to emotional upset.
All CBT theories of
psychopathology and interventions could be better integrating this theory into
their respective models. Steve’s discovery that humans learn to associate
stimuli in ways that differ from animals truly adds a whole new way to explain
the development of meaning. Interestingly, I have had the most heated
discussions of this theory with colleagues who study animal learning, not with
those who do therapy. It will take time to integrate relational Frame Theory
into the field but it will change the field.
The wave also makes an interesting clinical hypothesis concerning
acceptance. This model proposes that it is important to learn a new acceptance
response to the stimuli previously associated with a disturbed response. This is
different from the traditional cognitive interventions that identify, challenge,
and replace the dysfunctional thought. The new model suggests that
challenging is at best unnecessary, and at worst focuses the client on the
dysfunctional thought. This focus may reinforce the problematic idea. I think
there is merit to this idea. Dana Morriority and I surveyed therapists trained at
the Albert Ellis Institute. We asked them which type of interventions they
thought most effective in therapy. We included in the survey several types of
challenging techniques and teaching a new rational thought. By far, therapists
agreed that teaching the new thought was the most effective technique. So
perhaps, challenging dysfunctional thoughts and irrational beliefs is not a
necessary or even desirable part of cognitive restructuring.
10. How do you see the integration of cognitive and behavioral principles
(within theories and techniques) in present CBT? Is it real or it is just a cohabitation based on the common evidence-based background?
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This question represents the most difficult problem in CBT. All
cognitively oriented theorists have developed therapies that employed both
cognitive and behavioral interventions. Many behavioral theorists have argued
that behavioral interventions are sufficient for change and cognitive
interventions add nothing. This question reminds me of a debate that my
mentor Howard Kassinove arranged while I was a student between Joe Wolpe
and Al Ellis.
Joe spoke first and drew a human head on the chalk board and
proceeded to show that two pathways connected the external stimuli to the
hypothalamus and emotional arousal. The first pathway passed through the
lower area of the brain below the cortex around the thalamus. He described it
was fast, and occurred with little awareness. Joe thought this pathway
occurred through conditioning and responded to primarily behavior
interventions such as systematic desensitization and exposure. The second
pathway went up from lower areas to the brain and into the cortex and then
back down to the hypothalamus. Joe referred to this as the cognitive pathway
and suggested that it was slower and involved conscious awareness. Arousal
mediated through this path responded to cognitive interventions. Joe then
asserted that 90% of human disturbance was mediated by the subcortical path
and responded to behavioral interventions, and 10% of cases could be
accounted for by the cortex path and responded to cognitive techniques.
Al took the podium to speak and the students all expected he would
argue with Joe. Al commented that he agreed basically with Joe’s account.
However he disagreed with one small point. Ten percent of cases were
mediated by the subcortical conditioning pathway and 90% by the
cortex/cognitive pathway. For thirty minutes they went back and forth on the
percent of cases mediated by the two paths.
This theoretical position is presented in more detail today by the
English psychologists Power and Dalgleish. I think that it is possible that we
have two pathways. The problem with positing a cognitive-only pathway is
that a cortical connection to emotional disturbance is too slow. Any organism
that relied on it would probably get eaten by a predator before they got
frightened. So, I would propose that the continued activity of cognitive
excitation of emotions leads to a subcortical pathway to be created for the sake
of speed. Behavioral interventions alone are needed to break this non
cognitive path. However, behavioral interventions alone leave the cognitive
path active. The continued excitation of this path would not only lead to
emotional arousal but reestablish the non-cortical, lower level connection. So,
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I think that a combination of cognitive and behavioral interventions would
produce improvement with the least likelihood of a relapse.
11. How do you see the relationship between cognitive science and CBT?
Unfortunately, this relationship is not strong enough. I think few
cognitive behavior therapists know much cognitive psychology. However,
cognitive psychology may not investigate topics that are relevant to CBT.
Much of cognitive psychology focuses on cold cognition and information
processing of non-affective content. Such research may not answer the
questions that interests therapist. We are interested in the cognitions that
arouse emotions and on social cognition.
12. How do you see the role of CBT (a) in the effort of psychotherapy
integration and (b) in the evidence-based movement in psychotherapy?
I have always seen CBT as and integrative form of therapy. I have
remained an active member of AABT and now ABCT because I have found
the organization to be open and accepting of new ideas. Within behavior
therapy, cognitive therapies were added. The transtheoretical ideas of
Prochaska and DiClemente on the stages of change enter CBT and have
become a standard part of the knowledge. Also, the idea of the therapeutic
alliance has become an added part of our knowledge. When we discovered
that some clients in the pre-contemplative stage of change did not always
respond to the active stage techniques of CBT, people Miller and Rollnick’s
notion of motivation enhancement techniques. This idea developed from Carl
Roger’s work. At recent CBT conferences one finds many presentations of
mindfulness interventions a non-western idea. Family interventions and the
importance of interpersonal interactions have been part of CBT since Patterns
ides of coercive family process decades ago. I could go on. But I have
remained active in this group because it has shown responsiveness to data.
Ideas that have empirical support need to be explained and incorporated into
our armamentarium.
13. Both Aaron T. Beck and Albert Ellis are living icons who keep the CBT
community close and in unity. How do you see CBT post Beck and Ellis?
I think the period of great names in psychotherapy as a whole and in
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CBT is over for a while. Thomas Kuhn in his book The Structure of Scientific
Revolutions, identifies phases of what he calls normal science punctuated by
periods of revolution. During such periods scientists confront small problems
and fill in the knowledge gaps in problems posed by the primary paradigm.
When normal science produces conflicts that a paradigm cannot resolve, the
stage is set for the introduction of a new revolutionary paradigm. Psychology
has been described as in a pre-paradigm state of development and big, highly
discrepant ideas with little support have competed for attention. We have now
entered a period of integration of these ideas and intense scientific inquiry.
But a scientific method for investigation has been agreed upon in the field.
Many researchers are turning out scientific papers in the psychotherapy. I
think we will settle down in this phase of normal science. We have too many
theories in psychotherapy in general and also in CBT. We require time to sort
out the facts before the next big ideas come along that will resolve problems
that normal science cannot resolve. Big theories by famous scientists will
come along to resolve conflicts that the data cannot resolve.
One factor may change this. Psychotherapists buy books from people
that promise new break-through ideas. Marketing forces may create the next
big names in psychotherapy or CBT rather than big, new ideas. Writers can
promise break-through ideas before they have scientific data to support those
ideas.
14. How do you see CBT in the next 25 years? What is the path we should
follow? What are the main dangers for the future of CBT? What is wrong now
in CBT?
I think I answered this above. We have too many competing theories
and too much allegiance theories and theorists.
15. What are the main plans of your organization regarding CBT?
We have a strategic retreat of the ABCT leadership schedule for this
summer. We plan to develop an agenda for the organization for the next three
years. Many people see CBT as the scientific area of psychotherapy and want
to focus on dissemination. So this topic will be a main focus of our retreat. I
have some problems with the notion of research dissemination. Because
psychology, and by extension psychotherapy, is in a pre-paradigm state. Many
therapists have ideas that they want to keep and they are not interested in
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hearing about our dissemination of research ideas. They have different ideas
of what constitutes knowledge. We need to engage therapists in a dialogue if
we are to influence them. But a dialogue implies that we listen to them. Can
we do this or do we already have the truth that we need to teach others? Thus,
therapists of other orientations may respond to dissemination attempts as
proselytizing. I would like to help my CBT colleagues engage therapists of
other orientations in a dialogue that we all can learn from.
III. International Association for Cognitive Psychotherapy & Academy of
Cognitive Therapy, USA
?? Robert L. Leahy (B.A., M.S., Ph.D., Yale University) completed a
Postdoctoral Fellowship in the Department of Psychiatry, University
of Pennsylvania. He is the President of the International Association
for Cognitive Psychotherapy, President of the Academy of Cognitive
Therapy, Director of the American Institute for Cognitive Therapy
(NYC), Clinical Professor of Psychology in Psychiatry at WeillCornell University Medical School, Associate Editor of The Journal
of Cognitive Psychotherapy (serving as Editor 1998-2003), and Editor
of Cognitive Behavior Therapy Book Reviews. He was recently elected
to be President-Elect of the Association for Behavioral and Cognitive
Therapy (ABCT).
Q 1. How would you briefly define CBT and who do you consider to be the
major founders/originators of CBT?
A
I think of cognitive-behavioral therapy as a model of change that
emphasizes modifying unhelpful thoughts by using behavioral experiments.
So, if a patient is depressed and has the unhelpful thought, “I can’t do
anything”, using an activity schedule and keeping track of activities, rating
them for pleasure and competence, allows the patient to test the thought.
Who are the founders/originators of the CBT approach? This is a very
complicated question, because it involves both the behavioral and cognitive
components. I view the founders of the behavioral approach as including
Pavlov, Watson, Skinner, Wolpe, Mowrer, Arnold Lazarus, Bandura, and
others. They helped establish the importance of association learning and
operant conditioning. Of course, learning theory has gone far beyond simple
contiguity learning—as evidenced by the work by Robert Rescorla — who,
along with others, recognizes the importance of “cognitive elements” in
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learning, such as expectancies and the recognition of relationships and
prediction. In regard to cognitive therapy, I would argue that George Kelly’s
1955 book, The Psychology of Personal Constructs, was seminal and would
probably be viewed today, if one read it, as one of the most profound models
of cognitive therapy. Unfortunately, Kelly wrote the book during the heyday
of psychoanalysis (so he was viewed as too cold and rational) and was
criticized by the newer Rogerians for being too rational. The behaviorists at
the time rejected the idea of cognition as an important focus of change. How
unfortunate. After Kelly, we certainly view Ellis and Beck as the founders of
contemporary cognitive therapy or rational emotive behavior therapy. Despite
their detractors, their work continues to have major influence and has been the
underpinning for the excellent advances in specific models of anxiety and
depression treatment.
2. As you know, there are many schools of CBT. What do you think are the
core common assumptions of these various schools? Is it correct to talk about
“various schools of CBT” or it would be better to reframe this as “various
strategies/theories/models part of a coherent CBT paradigm”?
I would like to view it as various strategies rather than various schools
because I see patients every day and I need to draw on whatever works.
Unfortunately, there is some emphasis on claiming that one “school” has a
monopoly on the truth.
3. What are the typical and specific aspects of the CBT clinical diagnosis?
How is it related to the evidence-based assessment movement?
I think that clinical diagnosis, given the DSM IV R can be enriched by
the individualized cognitive and behavioral assessment of a patient. The DSM
is a bit misleading since most patients have elements of a variety of disorders.
Consequently, I think there is a good case for transdiagnostic processes, such
as emotional regulation, experiential avoidance, underlying assumptions about
self, world, and emotions, contingencies for behavior, etc.
4. How do you see the role of the cognitive conceptualization/mediation
currently in CBT, and how is it related to therapeutic myths? Do we currently
have strong enough theories to conceptualize pathology or more research is
needed to develop new theories? What is your opinion on theoretical
Quo Vadis CBT?
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eclecticism?
I think that the claim that cognitive mediation is unimportant often
fails to recognize the vast body of research that shows that latent schemas,
attribution styles, assumptions, and personality styles are predictive of course
of illness and relapse. Schemas are by nature often implicit and, therefore, the
individual may not be fully aware of their schema. However, this does not
imply that schemas are not vulnerabilities. For example, Segal’s work on
implicit schemas— utilizing a model whereby schemas can be activated –suggests that these schemas are vulnerabilities. Attribution style is predictive
of future depression, as the work by Alloy, Abramson, Reilly-Harrington, et al
illustrates.
The mistake, I think, is to reduce everything to schemas and to argue
that finding change in depression where schemas (or thoughts) are not
predictive of change is based on the assumption that cognitive mediation is a
necessary and sufficient condition. This extreme cognitive view is a myth.
5. What is your opinion of the relationship among irrational beliefs, core
beliefs, and automatic thoughts? Do you think that rigid thinking
(demandigness) is one of the core mechanisms involved in psychopathology?
How about the role of the (cognitive?) unconscious in CBT?
Again, like many “schematic models”, one gets the impression that
core beliefs lead to assumptions that lead to automatic thoughts. This is a
simple way to portray things, but it may obscure that the “arrows” go back and
forth. For example, automatic thoughts (“He thinks I’m foolish”) may lead to
assumptions (“I need to be perfect”) and behavioral adaptation (“work really
hard”) that feed into core beliefs (“failure”, “fraud”, “incompetent”). Thus, I
think you can start by modifying any level in the cognitive model (e.g.,
automatic thoughts) and affect other levels (“schemas”)
6. What is the role of the therapeutic alliance in current CBT? What is your
view on the role of transference and counter-transference in CBT?
I have written about the therapeutic alliance in my book, Overcoming
Resistance in Cognitive Therapy, and in my edited book with Paul Gilbert,
The Therapeutic Relationship in the Cognitive Behavioral Psychotherapies. I
think that some CBT people underestimate the importance of the alliance—
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and often have high dropouts and engage in rather superficia l therapy. The
patient’s transference can consist of any number of modes of resistance,
including the victim role, validation resistance, sunk costs, emotional
schemas, cognitive consistency (including rigid schemas), risk-aversion, etc. I
lay out descriptions of these and how to modify them in the resistance book.
Of particular interest to me is the counter-transference. I have developed a
questionnaire of the therapist’s schematic issues that I find helpful in
illustrating how your own core beliefs (demanding standards, fears of
abandonment, approval seeking) can interfere in the therapeutic relationship.
7. What is the state of techniques in CBT and how do you see them in relation
with therapeutic rituals? Do we have powerful enough techniques to change
the etiopathogenic mechanisms once identified, or we still need research to
invent new techniques? What is your opinion on technical eclecticism?
I have written a book, Cognitive Therapy Techniques, that is widely
used by clinicians. My view is that we are constantly adding to our tool-box of
techniques—we now include a lot of emotional regulation work from DBT,
acceptance and commitment, emotion focused therapy—and techniques that
are derived from a meta-cognitive and a meta-emotional/emotion schema
model. The beauty of cognitive therapy is that it allows us to expand
endlessly with new techniques. The clinician can take a purely idiographic
approach with each patient— “Which techniques are going to work this
individual?” There is no panacea of techniques.
8-14 (unanswered)
15. What are the main plans of your organization regarding CBT?
Our organization in NYC— The American Institute for Cognitive
Therapy—provides a full range of theoretical models of treatment for a wide
range of problems. We have traditional Beckian therapy, but we use
mindfulness, acceptance and commitment, DBT, operant conditioning,
emotional schema therapy, emotion focused therapy, and other approaches as
they seem appropriate. We adjust the therapy to the patient rather than
adjusting the patient to a preconceived model. Our website provides a
tremendous amount of information on a wide range of problems— see
www.cognitivetherapynyc.com.
Quo Vadis CBT?
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IV. Japanese Association of Behavior Therapy
?? Junko Tanaka-Matsumi, Ph.D. is Chair of the International
Committee of the Japanese Association of Behavior Therapy and
Representative of the World Congress Committee of the World
Congress of Behavioral and Cognitive Therapies (WCBCT). He is a
professor at the Department of Integrated Psychological Science,
Kwansei Gakuin University, Japan.
Q 1. How would you briefly define CBT and who do you consider to be the
major founders/originators of CBT?
A
I define CBT as a set of empirically-derived procedures to assess and
modify the individual’s behaviors, thoughts, and emotions. Some of the major
founders of CBT are Michael Mohoney, Donald Meichenbaum, Albert Ellis,
and Aaron Beck. Conceptually, I think it is also important to include Albert
Bandura.
2. As you know, there are many schools of CBT. What do you think are the
core common assumptions of these various schools? Is it correct to talk about
“various schools of CBT” or it would be better to reframe this as “various
strategies/theories/models part of a coherent CBT paradigm”?
The common assumptions are: (1) Targets of CBT include cognitions,
that is, what people say to themselves; (2) cognitions are closely related to
how the person acts and feels in the current environment, and (3) predict how
the person would act based on developmental learning (schema). I see CBT as
a set of strategies and models with varying emphases on functional or
structural aspects of cognitive behavioral activities.
3. What are the typical and specific aspects of the CBT clinical diagnosis?
How is it related to the evidence-based assessment movement?
A typical aspect is conducting functional assessment of automatic
thoughts in critical situations for various psychological problems. Specifically,
empirical CBT research has demonstrated that symptoms of anxiety disorders,
depression, and many other psychological problems are associated with
specific things people say to themselves (automatic thoughts).
These
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particular thoughts are specific to individuals and their situations but they also
have communalities for certain psychological disorders. CBT assessments
have contributed greatly to the evidence-based assessment movement. In
CBT, assessment data can guide which specific intervention methods to use
for the specific client’s target problems.
4. How do you see the role of the cognitive conceptualization/mediation
currently in CBT, and how is it related to therapeutic myths? Do we currently
have strong enough theories to conceptualize pathology or more research is
needed to develop new theories? What is your opinion on theoretical
eclecticism?
I am not sure if we can talk about theoretical eclecticism because no
theory is a self-contained theory. Instead, we have a set of principles that
guide our assessment and intervention. If you talk about models of anxiety
disorders, for example, there are more than several dominant models even
within the CBT domain. It is important to validate existing, effective models
of psychological disorders. In the process, we may discover new variables to
contend with. Clinical observations have become increasingly important to
bridge science and practice in CBT. Therefore, I am hoping for more
advanced findings from the clinical practice setting in the coming years, which
fuel into or blend with basic research. This process may generate new theories
as we fine-tune our observational skills.
5. What is your opinion of the relationship among irrational beliefs, core
beliefs, and automatic thoughts? Do you think that rigid thinking
(demandigness) is one of the core mechanisms involved in psychopathology?
How about the role of the (cognitive?) unconscious in CBT?
I do think that rigidity or lack of flexibility is one of the core features
of psychological disorders of which anxiety and depression are particularly
salient. Important point is to see how they are functionally related to
maladaptive behaviors in the person’s environment. As for the role of the
unconscious, this depends on the definition of the unconscious. Functional
assessment of cognitions can often increase one’s awareness of those
memories people have forgotten or have actively or passively avoided.
6. What is the role of the therapeutic alliance in current CBT? What is your
Quo Vadis CBT?
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Clinical Forum Section
view on the role of transference and counter-transference in CBT?
The therapeutic alliance is very important. Without it, it is difficult to
conduct effective CBT particularly if you are asking the client to perform
behavioral experiments. However, I do not think therapeutic alliance is a
special feature of CBT. Good working relationship is fundamental to good
therapy.
7. What is the state of techniques in CBT and how do you see them in relation
with therapeutic rituals? Do we have powerful enough techniques to change
the etiopathogenic mechanisms once identified, or we still need research to
invent new techniques? What is your opinion on technical eclecticism?
Different from theoretical eclecticism, I think technical eclecticism is
frequently and effectively employed in various psychotherapeutic practices
including CBT. There are great many techniques to effect therapeutic changes.
New techniques will be developed as natural process of scientific progress.
When I was a graduate student in the United States, we studied systematic
desensitization and exposure as main techniques to reduce fears and anxieties.
In the 1980s we learned more about interoceptive exposure to treat panic
disorders. In the 1990s we saw the development of treatment packages with
multiple techniques for specific disorders, all of which contributed to
empirically-valid, empirically-supported psychological treatments. Now we
see more broadly defined empirically-supported practice. In short, technical
eclecticism has existed for many years. I think it encourages creativity and
flexibility in CBT practice.
8. How do you see the distinction among feeling better, getting better, and
staying better in CBT, in relationship to the therapeutic strategy?
I think that the three goals and functions are closely related and each
may be achieved by using the same strategies. Staying better would need a
continued use and reinforcement of learned skills, as it seems to suggest
maintenance. I recall David Burns’ book titled “Feeling Better” for the CBTbased bibliotherapy of depression.
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9. Can we talk about several waves of CBT? Which are these and how do you
see their interrelations? Is it a cumulative development or not?
I think of waves of CBT in five ways as it stemmed from behavior
therapy early on: (1) functional analysis of behavior; (2) conditioning models
of fears and anxieties; (3) social learning theory; (4) waves of cognitive
therapy, self-control therapy, problem solving therapy, and rational emotive
behavior therapy, and (5) more recently, social constructivism and narrative
methods to reinforce the importance of the self-constructed meanings based on
experience.
10. How do you see the integration of cognitive and behavioral principles
(within theories and techniques) in present CBT? Is it real or it is just a cohabitation based on the common evidence-based background?
Theoretically and technically, I think integration is fairly effectively
accomplished. Typical examples are panic control treatment and CBT for
obsessive compulsive disorder. Integration is further evidenced in the
increased use of behavioral experiments in cognitive therapy. I do not take this
merely as a co-habitation. Effective therapies use integrated cognitivebehavioral techniques based on a cognitive-behavioral models. Eventually, we
need to see evidence in behavior change.
11. How do you see the relationship between cognitive science and CBT?
The relationship should be close. One interesting example is Wells &
Matthews’s (1994) “Attention and Emotion; A Clinical Perspective”.
Cognitive science, however, seems to cover much broader base with different
methodologies than what we typically see in CBT practice.
12. How do you see the role of CBT (a) in the effort of psychotherapy
integration and (b) in the evidence-based movement in psychotherapy?
(a) The movement for psychotherapy integration was started in part by
CBT therapists such as Marvin Goldfried. CBT people are empiricallyoriented and are always concerned with the issues of efficacy and
effectiveness of a particular intervention. (b) The role of CBT in the evidencebased movement in psychotherapy has been dramatic, visible, and productive.
Quo Vadis CBT?
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Clinical Forum Section
13. Both Aaron T. Beck and Albert Ellis are living icons who keep the CBT
community close and in unity. How do you see CBT post Beck and Ellis?
Their legacies will be inherited. CBT is research based so it is likely
that there will be modifications and new developments in CBT based on
clinical observations and clinically-informed research.
14. How do you see CBT in the next 25 years? What is the path we should
follow? What are the main dangers for the future of CBT? What is wrong now
in CBT?
I hope that CBT will be as prolific and even more effective than it is
now to improve diverse problems of living. The path I would like it to follow
is that of the evidence-based models and interventions. The other path will be
the consolidation of new CBTs such as Mindfulness training. I also look
towards a more multi-culturally effective CBT in diversifying society. The
issues of cultural sensitivity and cultural validity of CBT deserve much more
attention. CBT has changed the professional activities of the clinicians in the
last 50 years. CBT is always evolving and that is the most exciting part of the
CBT movement.
15. What are the main plans of your organization regarding CBT?
The Japanese Association of Behavior Therapy (President: Dr. Yuji Sakano)
was founded in 1971 and its current membership is approximately 1400. The
primary goal is to disseminate CBT in Japan and develop research on CBT.
JABT hosted the 2004 World Congress of Behavioral and Cognitive Therapies
(WCBCT) held in Kobe, Japan, along with two other hosts of the Japanese
Association of Behavior Analysis and the Japanese Association of Cognitive
Therapy. The WCBCT was held for the first time in Asia with a major
success. Importantly, in 2006, the 1st Asian Conference of Cognitive Behavior
Therapy was held in Hong Kong. The conference was successfully hosted by
the Chinese University of Hong Kong (Dr. Catherine So-Kum Tang) and
Queeensland University, Australia (Dr. Tian Po Oei). As reflected in these
international conferences, evidence-based CBT will have an increased
importance in training and clinical practice in Asian countries.
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V. Korean Association of Cognitive and Behavioral Therapies
?? Young Hee Choi M.D., Ph.D., President of the Korean Association
of Cognitive and Behavioral Therapies, Fellow of the Academy of
Cognitive Therapy, Associate Professor of Psychiatry, Clinical
Professor of Psychiatry, Inje University, Paik Hospital, Seoul Korea.
Q 1. How would you briefly define CBT and who do you consider to be the
major founders/originators of CBT?
A
CBT can be defined as a psychotherapy which helps relieve people of
their sufferings by teaching the principle that how we think affects our
feelings, physiological reactions and behavior. Acquiring perspectives about
cognitive models, understanding the relationship between automatic thoughts
and schemas, modifying one’s old beliefs into new beliefs and changing
behaviors are targets in CBT. Dr. Aaron T. Beck and Albert Ellis both deserve
to be called the major founders of cognitive therapy.
2. As you know, there are many schools of CBT. What do you think are the
core common assumptions of these various schools? Is it correct to talk about
“various schools of CBT” or it would be better to reframe this as “various
strategies/theories/models part of a coherent CBT paradigm”?
The core assumption of various schools of CBT is that thinking is the
center of human suffering and thinking is the product of schemas. My opinion
about various schools of CBT is: “various strategies/theories/models are part
of a coherent CBT paradigm.”
3. What are the typical and specific aspects of the CBT clinical diagnosis?
How is it related to the evidence-based assessment movement?
As we known, CBT has been developed to treat depression, but it
seems to have maximum effect on a variety of anxiety disorders, especially
panic disorder. Here we use cognitive conceptualizations in the assessment on
various mental problems. Through conceptualization, we have a clear target
and proper method of solving problems. The effects of CBT have been
Quo Vadis CBT?
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Clinical Forum Section
verified in randomized clinical trials, which are the fundamental methodology
related to the evidence-based assessment movement.
4. How do you see the role of the cognitive conceptualization/mediation
currently in CBT, and how is it related to therapeutic myths? Do we currently
have strong enough theories to conceptualize pathology or more research is
needed to develop new theories? What is your opinion on theoretical
eclecticism?
I cannot say that we currently have strong enough theories to
conceptualize pathology. However, we are presently using various cognitive
and behavioral approaches for various problems through cognitive
conceptualization. I think cognitive conceptualization is the only way of
understanding the patient. Through the process of cognitive conceptualization,
we can figure out the relationship among an individual’s symptoms,
interpretations, and schemas. Absolutely, I think we need more research to
develop new theories.
5. What is your opinion of the relationship among irrational beliefs, core
beliefs, and automatic thoughts? Do you think that rigid thinking
(demandigness) is one of the core mechanisms involved in psychopathology?
How about the role of the (cognitive?) unconscious in CBT?
Automatic thoughts definitely come from core beliefs (schemas). I
think that rigid ways of thinking (demandingness) can be seen as resistance to
changing schemas rather than as one of the main mechanisms of
psychopathology. If we do not or cannot know why we do something, this
may be called unconscious. I consider schemas as usually unconscious and
automatic thoughts as coming into consciousness by being triggered.
6. What is the role of the therapeutic alliance in current CBT? What is your
view on the role of transference and counter-transference in CBT?
Needless to say, the role of therapeutic alliance is not only the core of
CBT but the core of psychotherapy as a whole . Without the therapeutic
alliance, we cannot move to the next step, no matter how excellent our
therapeutic skills. Therefore, we as cognitive therapists need to redefine the
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analytic terminology of transference and counter-transference into cognitive
terminology.
7. What is the state of techniques in CBT and how do you see them in relation
with therapeutic rituals? Do we have powerful enough techniques to change
the etiopathogenic mechanisms once identified, or we still need research to
invent new techniques? What is your opinion on technical eclecticism?
CBT has been evolving. Techniques of CBT are now numerous and
can be chosen by the severity of patient’s problems and by the patient’s ability
to change. Only when we deal with serious and resistant problems, we need
additional techniques of other psychotherapy treatments such as imagination,
EMDR, or reinterpretation, etc.
8. How do you see the distinction among feeling better, getting better, and
staying better in CBT, in relationship to the therapeutic strategy?
This is a good question. Actually, we do not usually distinguish among
these states. There is no absolute standard for feeling and it is different
according to each individual. Can we say it is good if we do not feel bad? We
often say “so, so.” when we do not feel good or bad. People usually seem to
live like that. Therefore if we talk about therapeutic strategy, we usually start
to help our clients get better, teach them to feel better, and then teach them
strategies of staying better if it is possible.
9. Can we talk about several waves of CBT? Which are these and how do you
see their interrelations? Is it a cumulative development or not?
New waves of CBT can be listed, such as DBT (Dialectical Behavior
Therapy), schema therapy, ACT (Acceptance and Commitment Therapy),
Mindfulness Based Cognitive Therapy, and so on. Schema therapy is different
from traditional CBT in the method of touching schemas. Compared to the
traditional method of downward arrow techniques of finding and modifying
schemas starting from automatic thoughts, schema therapy usually deals with
schemas more directly. This is an epochal development in solving personality
problems, which was a relative weakness of traditional CBT. Unlike
traditional CBT, which emphasizes the changes of thoughts, ACT usually
emphasizes acceptance. It teaches concepts of meditation through more simple
Quo Vadis CBT?
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Clinical Forum Section
and paradoxical exercises to help people live with value, and use their
interests and energy for “here and now.” Both DBT and MBCT attempt to
integrate Zen or meditation in order to surpass the limits of cognitive and
behavior therapy. This contains the message that we need to accept if we
cannot change or eliminate our pain. So we can see these waves as cumulative
development, as a result of the endless pursuit to get over pain.
10. How do you see the integration of cognitive and behavioral principles
(within theories and techniques) in present CBT? Is it real or it is just a cohabitation based on the common evidence-based background?
I regard the integration of cognitive therapy and behavioral therapy as
a natural process similar to the need of working through the process of
behavioral change after having insights in analytic psychotherapy.
11. How do you see the relationship between cognitive science and CBT?
I think various principles of cognitive science function as the nurturing
sources of CBT because cognitive behavioral therapists need to analyze and
understand how clients’ schemas were built from various experiences
(information) and how schemas affect clients in their current situation.
12. How do you see the role of CBT (a) in the effort of psychotherapy
integration and (b) in the evidence-based movement in psychotherapy?
(a) Psychotherapy has to be dealt with as not only a science but also as
state of the art. As a matter of psychotherapy integration, CBT stands in the
center.
(b) CBT has evolved and survived especially because it took the methodology
of evidence-based approaches.
13. Both Aaron T. Beck and Albert Ellis are living icons who keep the CBT
community close and in unity. How do you see CBT post Beck and Ellis?
I am impressed by the notion of ‘post Beck and Ellis’. I think that
CBT will surely evolve as an integrated psychotherapy. I predict that
integrated CBT will take the form of a more modernized and comfortable
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Clinical Forum Section
client-centered
transportation.
psychotherapy,
parallel
with
high
speed
Internet
and
14. How do you see CBT in the next 25 years? What is the path we should
follow? What are the main dangers for the future of CBT? What is wrong now
in CBT?
There are many people who choose CBT without verification.
Therefore, I think that professionals with proper certification have to be
differentiated from other people. The ideal way is that CB therapist should
have supervision from a competent certified therapist, who can show them
how to treat their clients, and report the effects of their therapy through case
reports or research papers.
15. What are the main plans of your organization regarding CBT?
I am the founder and president of the KACBT (Korean Association of
CBT), and have developed the Mettaa Institute of CBT for training competent
CB therapists, certified by the ACT (Academy of Cognitive Therapy) in the
future. We are operating a 3-year curriculum for mental health professionals at
the Mettaa Institute of CBT. As part of this curriculum, we invite 3-4
internationally well-known cognitive therapists and organize 2-3 day
workshops annually. The KACBT has about 300 members and holds annual
conferences in spring and autumn. In the future, we are planning to have an
Asian CBT conference regularly, with Japanese and Chinese CBT therapists.
VI. Brazilian Society of Cognitive Behavioral Therapy
?? Renato M. Caminha is professor, researcher and coordinator of the
cognitive behavioral psychotherapies specialization program of the
Universidade do Vale do Rio dos Sinos – UNISINOS – RS, BR. He is
President of the Brazilian Society of Cognitive Behavioral Therapy –
SBTC. He teaches specialization courses in over ten states in Brazil,
mainly on childhood and anxiety disorders, particularly posttraumatic
stress disorder. He has developed a software for the extinction of the
traumatic memories called “Caixa de Memória” (Memory Box).
Q 1. How would you briefly define CBT and who do you consider to be the
major founders/originators of CBT?
Quo Vadis CBT?
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Clinical Forum Section
A
CBT is basically a model of psychotherapy that identifies, by
monitoring (checking) thoughts, the main dysfunctional schemas of certain
types of psychopathology, or during a problem that a patient may have. It is
based on the idea that cognitions can be monitored and modified. Thoughts
modulate emotions and influence behavior. By changing the way of thinking,
of interpreting facts, we change the dysfunctional schemas and, therefore, we
change our patients’ problems.
There is no doubt that Aaron Beck and Albert Ellis are considered the
creators of this paradigm, although I believe that the behaviorist Wolpe has
shown a great part of the way.
2. As you know, there are many schools of CBT. What do you think are the
core common assumptions of these various schools? Is it correct to talk about
“various schools of CBT” or it would be better to reframe this as “various
strategies/theories/models part of a coherent CBT paradigm”?
The main schools are Beck´s Cognitive, Ellis’ Rational EmotiveBehavior Therapy (REBT) and Mahoney´s Constructivism. There are also the
post-rational, and possibly other schools will still be developed. The core of
the paradigm is the acceptance of the principles described above, and schools
differ in their view of the way to obtain results. Placing more emphasis on
emotions, thoughts or behaviors are nuances that make the difference among
them. I would rather say “various strategies/theories and models of a CBT
paradigm”.
3. What are the typical and specific aspects of the CBT clinical diagnosis?
How is it related to the evidence-based assessment movement?
Cognitive behavioral therapies use the so-called “atheoretical
diagnosis”, described in manuals like DSM IV – APA. It is important to work
on identifying a diagnosis. Considering that some disorders have already been
well described, we can say that if we know a patients’ diagnosis, we know his
way of thinking – not the subject or the ideas, this is personal – but we know
the basic algorithms of his main dysfunctional schemas. In this way, we are
totally related to what we consider evidence-based …

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