(p. 1) The development and principles of cognitive–behavioural treatments
The empirical foundations of cognitive–behavioural approaches to psychological problems can be traced back to the early part of this century. The Darwinian view that there is continuity between man and the lower animals allowed ‘animal models’ of behaviour to be applied to the study of how psychopathology developed and was maintained, with the assumption that principles derived from animal learning research could be generalized to man.
Early work identified two principles of animal learning. The first principle was based on the work of Pavlov and other Russian physiologists. They conducted experiments with dogs where first a bell was rung, and then food was given. After this sequence of events had been repeated a number of times, the dogs began to salivate as soon as the bell was rung, before the food was given. This phenomenon became known as classical conditioning. As food automatically produces salivation before learning (conditioning) has occurred, it was termed an unconditioned stimulus; the response of salivation to the food was termed on unconditioned response. Before any learning had taken place the bell did not elicit salivation. However, after several pairings of the bell and food, the sound of the bell (the conditioned stimulus) came to elicit salivation (the conditioned response). This paradigm is represented in Fig. 1.1. Pavlov also investigated what happened to a conditioned response when the bell ceased to be followed by the unconditioned stimulus (the food). After a number of such trials, the conditioned response gradually extinguished.
The Russian investigators also found that emotional responses such as fear can be conditioned. For this reason the classical conditioning paradigm has considerable implications for the understanding of psychopatho-logical phenomena. In an unconditioned state, for example, an animal will respond emotionally to an electric shock, with an unconditioned response including an increase in heart rate. It will not initially respond in this way to an unconditioned stimulus such as a red light. However, if the red light is systematically paired with electric shock, the animal will begin to respond to the red light with a conditioned fear response. Thus the red light will have become a conditioned fear stimulus for the animal.
(p. 2) The second principle, known as operant conditioning, derived from observations made in the USA by Thorndike, Tolman, and Guthrie. In a series of experiments they found that if a particular behaviour was consistently followed by a reward the behaviour was more likely to occur again. This phenomenon became known as the ‘Law of Effect’, which states that behaviour which is followed by satisfying consequences will tend to be repeated and behaviour which is followed by unpleasant consequences will occur less frequently. Skinner extended this principle by defining reinforcers in terms of the effect that they have on an individual’s behaviour, not simply whether they appear to be either rewarding or unpleasant. Thus, in operant conditioning, if a behaviour is followed by a particular event and the behaviour increases in frequency, then the behaviour is said to be reinforced (see Fig. 1.2). Positive reinforcement describes the situation where a behaviour (e.g. being on time) occurs more frequendy because it is followed by positive consequences (e.g. praise). Negative reinforcement describes the situation where the frequency of a behaviour increases because it is followed by the omission of an anticipated aversive event (e.g. anxiety, someone else complaining). Thus the term reinforcement always refers to situations in which behaviour increases in frequency or strength. Two further types of consequence are associated with decreases in the frequency of a behaviour. Punishment describes the situation where a behaviour decreases in frequency because it is followed by an aversive event (e.g. electric shock). Frustrative nonreward describes the situation where a behaviour decreases in frequency because it is followed by the omission of an expected reward (e.g. not (p. 3) being praised). In using operant conditioning principles to help patients, treatments are planned using as reinforcers the events which have previously been shown to change behaviour in the desired direction; these are not necessarily those which intrinsically appear to be rewarding.
The development of these two conditioning paradigms and their subsequent integration by workers such as Hull and Mowrer were invaluable in the evolution of behaviour therapy. Of particular importance was the work of Mowrer (1947, 1960), who described a two-factor model (encompassing both classical and operant components) to account for fear and avoidance behaviour. He suggested that fear of specific stimuli is acquired through classical conditioning, and that as fear is aversive the animal learns to reduce it by avoiding the conditioned stimuli. Solomon and Wynne (1954) made the further important observation that if stimuli had become classically conditioned by previous association with strongly aversive stimuli, then avoidance responses to the conditioned stimuli were extremely resistant to extinction. That is, they demonstrated that avoidance responding to harmless stimuli could continue unabated long after the prior conditioning had ceased.
Early clinical applications of behavioural principles
Perhaps the most famous example of the application of behavioural principles to the problem of clinical anxiety was Watson and Rayner’s (1920) description of conditioning procedures carried out with ‘Little Albert’, an 11-month-old infant. They found that they were able to produce a conditioned anxiety response to a white rat by pairing the appearance of the rat with a loud noise. This conditioning of anxiety (p. 4) extended (generalized) to similar stimuli such as the experimenter’s white hair and cotton wool, but not to dissimilar stimuli. This work was adopted by Jones (1924), who applied Watson’s recommendations for treatment; she discovered that only two treatment methods were consistently effective, one being to associate the feared object with an alternative pleasant response (eating), the other being to expose the child to the feared stimulus in the presence of other children who were not fearful. It is notable that these methods closely resemble those later adopted by Wolpe (systematic desensitization) and Bandura (participant modelling) (see below).
The next major development was the work of the Mowrers in the late 1930s on enuresis. They regarded enuresis as a failure of the patient to respond to bladder distension by waking up. They associated bladder distention (onset of urination) with wakening and consequent sphincter contraction, so that after several trials bladder distension should result in sphincter contraction on its own, thus preventing urination. Treatment utilizing an electrical ‘bell and pad’ device proved effective (Mowrer and Mowrer 1938). The work of the Mowrers was important not only because of this impressive outcome, but because the behavioural formulation and treatment of enuresis were novel. This work was significant in the later development of behavioural formulations and treatment.
Developments in the 1950s included several attempts to encompass concepts from outside the behavioural sphere. Particularly influential was the work of Dollard and Miller (1950), who conceptualized psychoanalytic theory in learning theory terms, and included factors such as cultural influences within a behavioural framework. This work demonstrated the broader explanatory power of behavioural theory, and laid the foundations for subsequent cognitive–behavioural formulations which incorporated findings from cognitive and social psychology research.
In South Africa during the early 1950s, Joseph Wolpe began to report work on ‘experimental neuroses’ in cats. This work was similar to previous research, for example by Masserman (1943), except that Wolpe emphasized new techniques for the elimination of experimentally induced fear and avoidance. He became particularly interested in the production of conditioned fear. Thus if an animal experienced a small shock when it approached food, subsequendy the fear could be elicited by other situations which were similar to the situation in which the shock had previously been delivered. Wolpe proposed a neurophysiological explanation to account for this phenomenon. Since feeding was inhibited by conditions which elicited the ‘symptoms’ of the ‘experimental neurosis’, this suggested to him that conditioned fear and feeding were mutually antagonistic or reciprocally inhibiting. This led to the idea that feeding might be used to reduce the anxiety elicited by specific situations. Wolpe successfully demonstrated this in his experimental animals by feeding them in (p. 5) progressively closer approximations to the setting in which they had originally been shocked. He proposed that fear reduction could generally be accomplished by the simultaneous presentation of anxiety-provoking stimuli and stimuli evoking a response antagonistic to anxiety (the reciprocal inhibitor), provided that the antagonistic response was the stronger of the two. In order to ensure that the inhibitor was stronger, the anxiety-provoking stimuli were presented in a graded way, on a hierarchy, beginning with mildly anxiety-provoking stimuli.
In extending his work to humans, Wolpe considered three main responses which might act as reciprocal inhibitors: sexual responses, assertive responses, and progressive muscular relaxation. The most widely adopted of these was a modified and shortened version of Jacobson’s (1938) relaxation procedure, which Wolpe believed to have similar neuro- physiological correlates to the effects of eating. In Wolpe’s method, the patient was taught relaxation, then encouraged to progress step-by-step through a hierarchy of feared situations while maintaining the relaxation in order to reciprocally inhibit the fear response. Initially, Wolpe used in vivo (real life) exposure, then changed to imaginal presentation because of the greater controllability and ease of presentation this offered. This procedure, which became known as systematic desensitization, was carefully elaborated in Wolpe’s influential book Psychotherapy by reciprocal inhibition (1958), where it is made clear that patients were expected to carry out extensive in vivo homework between therapy sessions. Wolpe’s contribution to the field was considerable, and has been a major influence on the practice of behaviour therapy. Its importance lay not only in his use of a theoretical formulation based on clear and testable hypotheses to devise a dearly specified treatment strategy, but also in his description of the extensive clinical application of this therapeutic technique. However, the theoretical basis of reciprocal inhibition is no longer influential. This is because it has been established that exposure in real-life situations is the most effective way to bring about reductions in conditioned anxiety, and that neither grading the exposure nor the use of reaprocal inhibitors such as relaxation are necessary. Nevertheless, systematic desensitization provided the practical foundation and the theoretical impetus for the research which has led to the development of current exposure-based therapies.
Wolpe was reporting his work at an important time, when the efficacy of psychoanalytic approaches was undergoing critical appraisal, following Eysenck’s (1952) controversial review in which he argued that the improvement rates achieved by psychotherapy were no higher than the rates which would be expected if treatment were not given (spontaneous remission). At the Maudsley Hospital in London, Eysenck, Jones, Meyer, Yates, and Shapiro became interested in the application of conditioning theories to psychological problems, and held a series of seminars on this topic. From these discussions emerged a treatment approach exemplified (p. 6) in a series of detailed single-case investigations in which conditioning principles were successfully applied to clinical problems. The application of learning-based treatment at the Maudsley Hospital was extended with the involvement of Rachman, who had previously worked with Wolpe. Rachman was instrumental in the development of aversion therapy, behavioural medicine, and, especially, the behavioural treatment of obsessional disorders. Gelder, Marks, Mathews, and other colleagues at the Maudsley and Warneford Hospitals developed and elaborated exposure treatments for phobic disorders. At the same time American workers, such as Davison (1968), were also looking in detail at the process of desensitization and other fear reduction techniques, and demonstrated that in vivo exposure was the essential effective ingredient. The theoretical basis of the exposure approach is that feared objects are stimuli to which anxiety has become conditioned (conditioned stimuli), and that the conditioned fear has failed to extinguish because the patient has developed avoidance and escape behaviours which prevent the individual from being fully exposed to the feared stimuli. In order for fear to extinguish, the patient has to be exposed to the feared stimuli and not to escape (and thereby avoid exposure) once exposure has begun. Exposure should continue at least until anxiety begins to decline. Although this technique is similar to systematic desensitization, it proceeds much more quickly. One reason why behavioural approaches to fear reduction became influential was that their effectiveness was systematically investigated in controlled trials (e.g. Paul 1966; Marks 1975).
A parallel and conceptually related development to fear reduction was the attempt of early behaviour therapists to induce or increase the anxiety associated with unwanted stimuli or behaviours. This approach was called aversion therapy, and was used mainly to treat alcohol problems and deviant sexual behaviour. External stimuli, thoughts or behaviours associated with the undesired response were paired with an aversive stimulus, such as an unpleasant electric shock. After several such pairings, the original stimuli alone should elicit the same response produced by the aversive stimulus; that is, they should elicit conditioned anxiety. The initial enthusiasm for this approach declined both for ethical reasons and because it proved to be ineffective (Rachman and Teasdale 1969). Covert sensitization, a treatment method where thoughts of the unwanted behaviour are paired in imagination with unpleasant stimuli (e.g. arrest, humiliation), is a less emotive alternative approach (Cautela 1967), although its efficacy is uncertain.
The early 1960s saw a further expansion of behavioural treatments into a wide range of problems beyond fear reduction. This expansion was mainly based on studies which employed single-case designs, which have been an important element in the behavioural approach since Shapiro’s (1961a, b) seminal papers on single-case methodology. Usually, single-case (p. 7) experiments involve obtaining a series of repeated measures of a clinically relevant variable at regular intervals (a time series); at a predetermined point in this series, an intervention is introduced, and the effect of this intervention is assessed according to changes in the variable. The effects of a variety of intervention strategies can be evaluated in this way. Later, complex designs which allowed single-case experiments to be applied to a wide range of clinical and research issues as part of routine clinical practice were developed (see Barlow, Hayes, and Nelson 1984). Although this methodology is theoretically not confined to cognitive–behavioural treatments, it has become intimately associated with the application of the cognitive–behavioural approach, and plays a continuing role in its development.
Applications of operant techniques: applied behaviour analysis
During the late 1950s, the potential applications of the operant approach (known as applied behaviour analysis) were described by Skinner and Lindsley, but no treatment work was carried out until the early 1960s. The first applications of operant techniques to clinical problems focused on measuring and changing the laboratory behaviour of mentally handicapped people and young children. In early applications to adult psychiatric problems, Ayllon worked on changing psychotic behaviour (such as violent acts, psychotic talk, and inappropriate eating behaviour) in institutionalized patients, using cigarettes and praise as reinforcers, and the withdrawal of attention from the patient as a means of extinction. He was able to demonstrate that disturbed behaviours would increase or decrease according to whether the behaviour was reinforced or reinforcement was withdrawn. This work illustrated the importance of Skinner’s principle that reinforcement should be defined in terms of its effect on behaviour (see p. 2). Thus, for one patient it may be reinforcing to eat alone in a single room, while for another patient it may be reinforcing to eat with other patients in the dining room.
In 1961, Ayllon and Azrin designed a hospital ward environment in which reinforcers were applied to systematically change patients’ behaviour. This system came to be known as a token economy because, as reinforcers, they used tokens which could be exchanged later for a range of privileges from which the patients could choose (Ayllon and Azrin 1968). This work was highly influential because it demonstrated that psychological intervention could be effective in patients (especially those with chronic schizophrenia) not previously regarded as amenable to such approaches. This study and later token economies all emphasized the importance of social reinforcement, particularly as an aid to both longer-term generalization (extension to other settings) and the maintenance of (p. 8) desired or acceptable behaviours. More recent work has cast doubts on the theoretical basis of the token system: for example, Hall and Baker (1986) indicated that the feedback and specific guidance about performance at the time the tokens were given were the most important factors in such programmes. Nevertheless, the development of token economies was highly significant in terms of encouraging a general approach to treatment in rehabilitation settings. The use of structured social reinforcers (praise and attention by the therapist) was more widely adopted than the use of tokens, and the emphasis on altering and structuring social interactions remains an important influence in helping patients with schizophrenia (e.g. Falloon, Boyd, and McGill 1984).
Consolidation and elaboration of the behavioural approach
The 1970s saw the full emergence of behaviour therapy, with numerous new techniques being developed and experimentally validated. By the end of the decade there was general acceptance of these treatment approaches. Behaviour therapy became the treatment of choice for many disorders, such as the use of in vivo exposure with phobias, obsessions, and sexual dysfunctions, and operant and goal-setting techniques in rehabilitation. Sex therapy developed from Masters and Johnsons’ pioneering work into the physiology of sexual responses rather than from behavioural research into sexual dysfunction. However, the emphasis on the empirical evaluation of treatments, and on operational definitions of treatment strategies, has gradually led to the inclusion of sex therapy in the mainstream of cognitive behaviour therapy. A further extension of behavioural approaches was the development of behavioural medicine, a term coined by Birk (1973) to describe the application of biofeedback to medical disorders. In biofeedback, patients learn to control physiological responding by receiving immediate information about changes occurring in the physiological system. Behavioural medicine later came to encompass a much wider field, including the application of physiological principles of treatment to disorders with a purely physical origin (e.g. painful burns), to those with a possible psychological aetiology (e.g. irritable bowel syndrome, psychogenic chest pain) and to the modification of risk factors (e.g. smoking). This period was also marked by the refinement of existing techniques (such as reducing the time required for effective exposure to bring about fear reduction and the development of abbreviated forms of relaxation) and the introduction of novel approaches (such as anxiety management training and social skills training).
Another major development was the adoption of a ‘three systems’ approach. Lang, Rachman, and others proposed that psychological problems could usefully be conceptualized in terms of loosely linked response (p. 9) systems. The systems proposed were behavioural, cognitive/affective, and physiological. These systems, although linked, do not necessarily change at the same time, in the same way, or even in the same direction; thus they are said to be desynchronous (Rachman and Hodgson 1974). There is no a priori reason to specify three systems as opposed to four or even more, and indeed it is probably useful to differentiate between the cognitive and affective systems, resulting in a four-system classification. However, this alternative to a unitary view of psychological problems was important both because it helped account for the wide range of symptom patterns which patients report, and because it resulted in more systematic and appropriate evaluations of treatment outcome. It increased the extent to which treatment could be shown to have specific effects; for instance, relaxation treatments are initially likely to affect physiological aspects of a problem more than behavioural or cognitive aspects.
The late 1960s and early 1970s also saw the beginnings of discontent with the strict behavioural notions which dominated early developments. In particular, Lazarus (1971) rejected what he believed to be mechanistic notions underlying the practice of behaviour therapy. He argued that the majority of behavioural treatments could not be conceptualized simply in learning theory terms, and proposed the adoption of ‘broad spectrum behaviour therapy’, in which techniques of empirically established efficacy are employed regardless of their theoretical basis. In practice, this approach was increasingly adopted by clinicians, although the research literature did not systematically examine the limitations of behaviour therapy until rather later. One of the least satisfactory results of this ‘technical eclecticism’ was a tendency to apply treatment in a prescriptive way, so that particular techniques were mechanistically applied to particular problems with little or no regard to a full behavioural assessment and formulation. More usefully, discontent with the strict behavioural approaches resulted in attempts to add cognitive components to existing techniques, opening the way for the systematic development and application of cognitive approaches.
Towards the middle and end of the 1970s, there was general acceptance of the usefulness of behaviour therapy. No longer faced with the need to demonstrate the efficacy of behaviour therapy per se, some of those working within the field began to turn their attention to those patients who did not benefit from behaviour therapy even when it was competendy delivered. This culminated in Foa and Emmelkamp’s book on treatment failures (1983). It became increasingly clear, for example, that it was insufficient to regard patients’ problems with compliance in terms of ‘poor motivation’, but attempts at more detailed behavioural analysis of poor compliance provided little in the way of further improvement. Another important development during this period was the attempt to develop behavioural theories and techniques which could be applied (p. 10) to other psychological problems, particularly depression. Lewinsohn (1974a), for example, proposed that depression is due to a reduced rate of response-contingent reinforcement. However, early attempts at therapy based on this notion (Hammen and Glass 1975) had limited success, probably because although patients engaged in a greater number of potentially reinforcing activities, they would often negatively evaluate the activities and their own successful performance. Thus it became increasingly evident that cognitive factors were involved in those patients who did not respond to simple behavioural treatment. These two developments contributed to die subsequent acceptance by many therapists of the importance of cognitive factors and the need to address them in therapy.
The integration of cognitive and behavioural approaches
Lang’s notion of three relatively independent response systems had laid the foundations for the acceptance of cognitive notions within the behavioural approach. In the context of behavioural psychology (as distinct from behaviour therapy), the importance of cognitive variables had already become increasingly recognized. The slower acceptance of cognitive views within behaviour therapy probably related to the continuing influence of Watson’s rejection of introspection, and the polemical position adopted by behaviour therapists towards other psychotherapies. Bandura’s work on observational learning was particularly important in drawing attention to cognitive factors in behaviour therapy. In this approach an individual learns by watching someone else performing a behaviour; the behaviour is learned best if the observer subsequendy performs the behaviour in question, but this is not a necessary condition. Bandura developed a model of self-regulation called self-efficacy, based on the idea that all voluntary behaviour change was mediated by subjects’ perceptions of their ability to perform the behaviour in question. Another important influence was an increasing interest in the concept of self- control, based on a three-stage model of self-observation, self-evaluation (setting standards), and self-reinforcement. This model generated a great deal of research effort in which cognitive constructs, including attribution and self-instruction, were made explicit.
Probably the first wholly cognitive approach to generate interest among behavioural researchers was self-instructional training (Meichenbaum 1975). The popularity of this approach related to its simple theoretical basis, and its similarity to the concept of ‘coverants’ (mental operant behaviour) within operant theory. Meichenbaum suggested that behaviour change can be brought about by changing the instructions that patients give themselves, away from maladaptive and upsetting thoughts to more adaptive self-talk. The more sophisticated cognitive therapy described by Beck (1970,1976), which is similar in many respects to Ellis’ (p. 11) (1962) Rational Emotive Therapy, was adopted much more slowly, but has now become die most important of the cognitive approaches. Initially, this approach was mainly applied to depression (Beck 1967). In contrast to the traditional psychiatric view of depression, Beck proposed that the negative thinking so prominent in the disorder is not just a symptom but has a central role in the maintenance of depression. This implies that depression can be treated by helping patients to identify and modify their negative thoughts.
Beck proposed that negative thinking in depression originates in attitudes (assumptions) which are laid down in childhood and later. In many situations these assumptions can be helpful, and guide behaviour. For example, an assumption such as ‘To be worthwhile I must be successful’ is likely to motivate considerable positive activity. However, the assumptions make the individual vulnerable to certain critical events. In die case of die above assumption, failing an examination might be such an event: this would be interpreted as a major loss and lead to the production of negative automatic thoughts, such as, ‘I am worthless’, ‘I am a failure as a person’. Such thoughts will lower mood, which in turn increases the probability that further negative automatic thoughts will occur, producing a vicious circle which tends to maintain the depression. Once depressed, a set of cognitive distortions exert a general influence over the person’s day-to-day functioning. These are manifest as the cognitive triad: negative view of self, current experience, and future. Other cognitive changes may maintain this view once it is elicited; for example, patients selectively attend to events which confirm their negative view of themselves. This model is elaborated more fully in Chapter 6. Beck (1976) extended the application of cognitive therapy to a wide range of emotional disorders.
The treatment described in this book represents an integration of cognitive and behavioural approaches. For this reason it is termed cognitive behaviour therapy. In this type of treatment the patient is helped to recognize patterns of distorted thinking and dysfunctional behaviour. Systematic discussion and carefully structured behavioural assignments are then used to help patients evaluate and modify both their distorted thoughts and their dysfunctional behaviours. Some aspects of treatment have greater behavioural emphasis and others a greater cognitive emphasis. As this book clearly demonstrates, cognitive–behavioural treatments have now been developed for most disorders encountered in psychiatric practice.
General principles of cognitive–behavioural treatment
In the cognitive–behavioural approach considerable emphasis is placed on expressing concepts in operational terms and on the empirical validation of treatment, using both group and single-case experimental designs in (p. 12) research settings and in everyday clinical practice. In order to ensure the replicability of findings, specification of treatment in operational terms, and the evaluation of treatment with a variety of reliable and objective measures are also emphasized. Much of the treatment is based on the here-and-now, and there is an assumption that the main goal of therapy is to help patients bring about desired changes in their lives. Thus treatment focuses on the opportunity for new adaptive learning, and on producing changes outside the clinical setting. Problem solving is an important integral part of treatment. All aspects of therapy are made explicit to the patient, and the therapist and patient endeavour to work in a collaborative relationship in which they plan together strategies to deal with clearly identified problems. Therapy is time-limited, and has explicitly agreed goals.
In this chapter we have summarized the earlier developments which have led to the acceptance of the applicability and usefulness of cognitive–behavioural treatment approaches for many psychiatric disorders. While the next few years will undoubtedly witness substantial changes and elaborations of these approaches, at the present time they offer both effective specific means of helping patients and also provide a valuable general approach to understanding psychiatric disorders and designing treatment programmes.
Barlow, D. H., Hayes, S. C., and Nelson, R. O. (1984). The scientist practitioner. Pergamon, New York.Find this resource:
Davison, G. and Neale, J. (1984). Abnormal psychology (3rd edn). Wiley, New York.Find this resource:
Kazdin, A. E. (1978). History of behavior modification: experimental foundations of contemporary research. University Park Press, Baltimore.Find this resource: