Cognitive Behavior

Therapy* 10
Learning Objectives
1. Identify common attributes 8. Describe the basic principles of
shared by all cognitive behavior strengths-based CBT.
approaches. 9. Describe Meichenbaum’s three-
2. Describe how the ABC model phase process of behavior
is a way of understanding the change.
interaction among feelings, 10. Describe the key concepts and
thoughts, and behavior. phases of Meichenbaum’s stress
3. Explain how cognitive methods inoculation training.
can be applied to change thinking 11. Identify the strengths and
and behavior. limitations of cognitive behavior
4. Discuss how REBT can be applied therapy from a multicultural
to school counseling. perspective.
5. Explain the unique contributions 12. Differentiate REBT from
of Aaron Beck to the development cognitive therapy with respect to
of cognitive therapy. how faulty beliefs are explored
6. Identify the basic principles of in therapy.
cognitive therapy. 13. Explain the main differences
7. Discuss application of the of Ellis, Beck, Padesky, and
cognitive behavior approach to Meichenbaum as applied to the
school counseling. practice of CBT.

*I would like to acknowledge Dr. Debbie Joffe Ellis for her review and additional input of REBT in
bringing this section of the chapter up to date. Appreciation also goes to Christine Padesky, PhD, for
updating the section on strengths-based CBT.

323
324 C h a pt er Te n

LO1 Introduction
Traditional behavior therapy has broadened and largely moved in the direction
of cognitive behavior therapy (CBT). Several of the more prominent cognitive-
behavioral approaches are featured in this chapter, including Albert Ellis’s ratio-
nal emotive behavior therapy (REBT), Aaron T. Beck and Judith Beck’s cognitive
behavior therapy (CBT), Christine Padesky’s strengths-based CBT (SB-CBT), and
Donald Meichenbaum’s cognitive behavior therapy. These approaches all fall under
the general umbrella of CBT.
All of the cognitive-behavioral approaches share the basic characteristics
and assumptions of traditional behavior therapy (see Chapter 9). Although these
approaches are quite diverse, they do share these attributes: (1) a collaborative rela-
tionship between client and therapist, (2) the premise that psychological distress
is often maintained by cognitive processes, (3) a focus on changing cognitions to
produce desired changes in affect and behavior, (4) a present-centered, time-limited
focus, (5) an active and directive stance by the therapist, and (6) an educational treat-
ment focusing on specific and structured target problems (Beck & Weishaar, 2019).
In addition, both cognitive therapy and the cognitive-behavioral therapies are based
on a structured psychoeducational model, make use of homework, place respon-
sibility on the client to assume an active role both during and outside therapy ses-
sions, emphasize developing a strong therapeutic alliance, and draw from a variety
of cognitive and behavioral strategies to bring about change. Therapists help clients
examine how they understand themselves and their world and suggest ways clients
can experiment with new ways of behaving (Dienes et al., 2011).
To a large degree, the various cognitive behavior therapy approaches are based
on the assumption that beliefs, behaviors, emotions, and physical reactions are all
reciprocally linked. Changes in one area lead to changes in the other areas. A change
in beliefs is not the only target of therapy, but enduring changes usually require a
change in beliefs. CBT therapists apply behavioral techniques such as operant con-
ditioning, modeling, and behavioral rehearsal to the more subjective processes of
thinking and internal dialogue. In addition, therapists teach clients to actively test
their beliefs in therapy, on paper, and through behavioral experiments. The cogni-
tive-behavioral approaches include a variety of behavioral strategies (discussed in
Chapter 9) as well as cognitive strategies as a part of their integrative repertoire.

Refer to the MindTap for this book to interact with video quizzes and various video
programs to expand your knowledge on topics relevant to Chapter 10.

Albert Ellis’s Rational Emotive Behavior Therapy

Introduction
Rational emotive behavior therapy (REBT) was the first of the cognitive behavior
therapies, and today it continues to be a major cognitive-behavioral approach. REBT
has a great deal in common with the therapies that are oriented toward cognition
340 C h a pt e r Te n

Don’t Work (2005), and the Cognitive Therapy Worksheet Judith Beck has three adult children, one of whom is
Packet (2011), as well as trade books with a cognitive a social worker specializing in CT.
behavioral program for diet and maintenance.

LO5 Aaron Beck’s Cognitive Therapy

Introduction
Aaron T. Beck developed cognitive therapy (CT) about the same time that Ellis
was developing REBT. They were not aware of each others’ work and created their
approaches independently. Ellis developed REBT based on philosophical tenets,
whereas Beck’s CT was based on empirical research (Padesky & Beck, 2003). Like
REBT, CT emphasizes education and prevention but uses specific methods tailored
to particular issues. The specificity of CT allows therapists to link assessment, con-
ceptualization, and treatment strategies.
Beck (1963, 1967) set out to create an evidence-based therapy for depres-
sion, and he tested each of his theoretical constructs with empirical studies
and conducted controlled outcome studies to determine how CT’s outcomes
compared with existing psychotherapy and pharmacotherapy treatments for
depression. Beck’s careful empirical approach was eventually adopted by col-
leagues around the world.
In the treatment of depression, cognitive therapy skills are some of the
most established tools for therapeutic change (DeRubeis et al., 2019). Evidence-
supported CT approaches were developed for many disorders including depression,
panic disorder, social anxiety, phobias, posttraumatic stress disorder, schizophre-
nia and other psychotic disorders, hypochondriasis, body dysmorphic disorder, eat-
ing disorders, insomnia, anger issues, stress, chronic pain and fatigue, and distress
due to general medical problems such as cancer (Hofmann et al., 2012; White &
Freeman, 2000).
Beck’s original depression research revealed that depressed clients had a nega-
tive bias in their interpretation of certain life events, which resulted from active pro-
cesses of cognitive distortion (Beck, 1967). This led Beck to believe that a therapy
that helped depressed clients become aware of and change their negative thinking
could be helpful. Unlike Ellis, Beck did not assert that negative thoughts were the
sole cause of depression. Beck’s research indicated that depression could result from
negative thinking, but it could also be precipitated by genetic, neurobiological, or
environmental changes. One of Beck’s early contributions was to recognize that
regardless of the cause of depression, once people became depressed, their thinking
reflected what Beck referred to as the negative cognitive triad: negative views of
the self (self-criticism), the world (pessimism), and the future (hopelessness). Beck
believed that this negative cognitive triad maintained depression, even when nega-
tive thoughts were not the original cause of an episode of depression (Beck, 1967;
Beck et al., 1979).
 C ogni ti ve B e havi or The r apy 341

Cognitive therapy (CT) has a number of similarities to both rational emotive

behavior therapy and behavior therapy. All of these therapies are active, directive,
time-limited, present-centered, problem-oriented, collaborative, structured, and
empirical. They include homework assignments (or out-of-session practice) and
require clients to explicitly identify problems and the situations in which they occur
(Beck & Weishaar, 2019). Similar to REBT and unlike behavior therapy, CT is based
on the theoretical rationale that the way people feel and behave is influenced by how
they perceive and place meaning on their experience. Three theoretical assumptions
of CT are (1) that people’s thought processes are accessible to introspection, (2) that
people’s beliefs have highly personal meanings, and (3) that people can discover
these meanings themselves rather than being taught or having them interpreted by
the therapist (Weishaar, 1993).
From the beginning Beck developed specific treatment protocols for each
problem, unlike Ellis who might teach similar philosophical principles to people
with anxiety, depression, or anger. Despite these differences, therapists who prac-
tice behavior therapy, REBT, and CT learn from each other, and considerable over-
lap exists in methods used by all three schools of therapy in contemporary clinical
practice. The highest standard of practice today is to offer the best “evidence-based
practice” regardless of its origins, so a therapist might use behavioral methods to
treat phobias and cognitive methods to treat panic disorder because research has
demonstrated these methods to be most effective in treating these problems. Many
therapists refer to themselves as offering cognitive-behavioral therapy regardless of
whether their original training was primarily in behavior therapy, REBT or CT.

A Generic Cognitive Model

Reflecting on 50 years of research and the various applications of cognitive therapy,
Beck has proposed a generic cognitive model to describe principles that pertain to
all CT applications from depression and anxiety treatments to therapies for a wide
variety of other problems including psychosis and substance use (Beck & Haigh,
2014). By linking psychological difficulties with adaptive human responses, Beck
believed the generic cognitive model “has the potential to be the only empirically
supported general theory of psychopathology” (p. 21). The generic cognitive model
provides a comprehensive framework for understanding psychological distress, and
some of its major principles are described here. Beck encouraged others to design
research to investigate the components of his model in an effort to reach the best
understanding possible of human cognition, behavior, and emotion. Let’s look at
some of the principles on which this model is based.
Psychological distress can be thought of as an exaggeration of normal adaptive human func-
tioning. When people are functioning well, they experience many different emotions
in response to life events and behave in ways that help them solve problems, achieve
goals, and protect themselves from harm. It is normal to sometimes withdraw from
relationships, avoid situations we don’t feel prepared to handle, or worry about
problems in the search of a solution. A psychological disorder begins when these
normal emotions and behaviors become disproportionate to life events in degree or
frequency. For example, when a person begins to worry most of the time, even about
342 C h a pt e r Te n

situations that most people take in stride, that person is showing signs of general-
ized anxiety disorder.
Faulty information processing is a prime cause of exaggerations in adaptive emotional and
behavioral reactions. Our thinking is directly connected to our emotional reactions,
behaviors, and motivations. When we think about things in erroneous or distorted
ways, we experience exaggerated or distorted emotional and behavioral reactions as
well. Beck identifies several common cognitive distortions:
◆ Arbitrary inferences are conclusions drawn without supporting evi-

dence. This includes “catastrophizing,” or thinking of the absolute

worst scenario and outcomes for most situations. You might begin your
first job as a counselor with the conviction that you will not be liked or
valued. You are convinced that you fooled your professors and some-
how just managed to get your degree, but now people will certainly see
through you!
◆ Selective abstraction consists of forming conclusions based on an

isolated detail of an event while ignoring other information. The sig-

nificance of the total context is missed. As a counselor, you might
measure your worth by your errors and weaknesses rather than by your
successes.
◆ Overgeneralization is a process of holding extreme beliefs on the basis

of a single incident and applying them inappropriately to dissimilar

events or settings. If you have difficulty working with one adolescent,
for example, you might conclude that you will not be effective counsel-
ing any adolescents. You might also conclude that you will not be effec-
tive working with any clients!
◆ Magnification and minimization consist of perceiving a case or situ-

ation in a greater or lesser light than it truly deserves. You might make
this cognitive error by assuming that even minor mistakes in counsel-
ing a client could easily create a crisis for the individual and might
result in psychological damage.
◆ Personalization is a tendency for individuals to relate external events

to themselves, even when there is no basis for making this connection.

If a client does not return for a second counseling session, you might
be absolutely convinced that this absence is due to your terrible per-
formance during the initial session. You might tell yourself, “This situ-
ation proves that I really let that client down, and now she may never
seek help again.”
◆ Labeling and mislabeling involve portraying one’s identity on the

basis of imperfections and mistakes made in the past and allowing

them to define one’s true identity. If you are not able to live up to all of
a client’s expectations, you might say to yourself, “I’m totally worthless
and should turn my professional license in right away.”
◆ Dichotomous thinking involves categorizing experiences in either-or

extremes. With such polarized thinking, you might view yourself as

either being the perfectly competent counselor (you always succeed
with all clients) or as a total flop if you are not fully competent (there is
no room for any mistakes).
 C ogni ti ve B e havi or The r apy 343

Our beliefs play a major role in determining what type of psychological distress we will
experience. Each emotional and behavioral disorder is accompanied by beliefs specific
to that problem. Consider two students who apply to college and are not accepted
to their first choice of school. One of the students becomes depressed, the other
becomes anxious. Depression is accompanied by negative thoughts about oneself
(“I’ve failed,” “Nothing will work out for me,” “I’ll never get into medical school”).
Anxious thoughts reflect overestimations of threat or danger (“Everyone will think
less of me when they find out I wasn’t admitted to that college”) and underestima-
tions of one’s coping (“I won’t know what to say to people about it”) and under-
estimation of resources (“These other colleges won’t prepare me well enough for
medical school”).
Central to cognitive therapy is the empirically supported observation that “changes in beliefs
lead to changes in behaviors and emotions” (Beck & Haigh, 2014, p. 14). If the students
in the previous example can change the way they think about not being accepted to
their first-choice school, their depression and anxiety are likely to be lessened. The
first student will undoubtedly feel less depressed once a more balanced view of the
rejection letter is adopted (“More good students apply than can be admitted. My
rejection does not mean I failed. I’m sure many students from my second choice
school go on to attend medical school.”). Similarly, the anxious student would ben-
efit from new beliefs as well (“I can tell others that I am disappointed that I did not
get into my first-choice college. Some people might think less of me, but those who
really care about me will understand that not everyone gets their first choice and
they will be supportive.”).
If beliefs are not modified, clinical conditions are likely to reoccur. Even without counsel-
ing or a change in beliefs, people often recover from feelings of depression or anxiety
and return to their usual healthy functioning. However, these feelings may return in
times of future stress or disappointment if their basic beliefs have not changed. In
studies of the long-term effects of treatments for depression and anxiety disorders,
DeRubeis, Keefe, and Beck (2019) report that cognitive therapy and other types of
CBT therapies have the lowest rates of relapse. “CT skills are arguably one of the
most established tools for therapeutic change” (p. 240). Many believe this is because
these therapies lead to enduring changes in beliefs.

LO6 Basic Principles of Cognitive Therapy

Cognitive therapy (CT) perceives psychological problems as an exaggeration of
adaptive responses resulting from commonplace cognitive distortions. Like REBT,
CT is an insight-focused therapy with a strong psychoeducational component
that emphasizes recognizing and changing unrealistic thoughts and maladaptive
beliefs. The client works in partnership with the therapist, assuming the role of a
learner in the therapy sessions and engaging in homework that is carried out in
daily life (Kazantzis et al., 2017). The goal of CT is to help clients learn practical
skills that they can use to make changes in their thoughts, behaviors, and emotions
and how to sustain these changes over time. Because cognitive therapy is a skills-
based approach, clients are able to employ the cognitive model and its methods in
effectively dealing with difficult situations they are likely to encounter after formal
therapy is terminated (DeRubeis et al., 2019).
344 C h a pt e r Te n

In cognitive therapy, clients learn how to identify their dysfunctional thinking.

Once clients identify cognitive distortions, they are taught to examine and weigh
the evidence for and against them. This process of critically examining thoughts
involves empirically testing them by looking for evidence, actively engaging in a
Socratic dialogue with the therapist, carrying out homework assignments, doing
behavioral experiments, gathering data on assumptions made, and forming alterna-
tive interpretations (Dattilio, 2000; DeRubeis et al., 2019; Tompkins, 2004, 2006).
From the beginning of treatment, clients learn to employ specific problem-solving
and coping skills. Through a process of guided discovery, clients acquire insight
about the connection between their thinking and the ways they act and feel.
Cognitive therapy is focused on present problems, regardless of a client’s diag-
nosis. The past may be brought into therapy when the therapist considers it essen-
tial to understand how and when certain core dysfunctional beliefs originated and
how these ideas have a current impact on the client’s difficulties (Dattilio, 2002).
The goals of this brief therapy include providing symptom relief, assisting clients in
resolving their most pressing problems, changing beliefs and behaviors that main-
tain problems, and teaching clients skills that serve as relapse prevention strategies.

Some Differences Between CT and REBT In both CT and REBT, reality testing
is highly organized. Clients come to realize on an experiential level that they have
misconstrued situations. Yet there are some important differences between these
two approaches, especially with respect to therapeutic methods and style.
REBT is often highly directive, persuasive, and confrontational, and the teach-
ing role of the therapist is emphasized. The therapist models rational thinking and
helps clients to identify and dispute irrational beliefs, logically and pragmatically. In
contrast, CT mainly uses Socratic dialogue, posing open-ended questions to clients
with the aim of getting clients to reflect on personal issues and arrive at their own
conclusions. CT places more emphasis on helping clients identify misconceptions
for themselves rather than being taught. Through this reflective questioning pro-
cess, the cognitive therapist collaborates with clients in testing the validity of their
cognitions (a process called collaborative empiricism). Therapeutic change is the
result of clients reevaluating faulty beliefs based on contradictory evidence that they
have gathered.
There are also differences in how Ellis and Beck view faulty thinking. Through a
process of rational disputation, Ellis works to persuade clients that certain of their
beliefs are irrational and nonfunctional. Beck views his clients’ distorted beliefs as
being the result of cognitive errors rather than being driven solely by irrational beliefs.
Beck asks his clients to conduct behavioral experiments to test the accuracy of their
beliefs. Cognitive therapists view dysfunctional beliefs as being problematic when
they are a distortion of the whole picture, or when they are too absolute, broad, and
extreme (Beck & Weishaar, 2019). For Beck, people live by rules (underlying assump-
tions); they get into trouble when they label, interpret, and evaluate by a set of rules
that are unrealistic or when they use the rules inappropriately or excessively. If cli-
ents decide they are living by rules that are likely to lead to misery, the therapist
asks clients to consider and test out alternative rules. Although cognitive therapy
operates within clients’ frame of reference, the therapist continually asks clients to
examine evidence for and against their belief system.
 C ogni ti ve B e havi or The r apy 345

The Client–Therapist Relationship

The therapeutic relationship is basic to the application of cognitive therapy.
Through his writings, it is clear that Beck believes effective therapists must combine
empathy and sensitivity with technical competence (Beck, 1987). The core thera-
peutic conditions described by Rogers in his person-centered approach are viewed
by cognitive therapists as being necessary, but not sufficient, to produce optimum
therapeutic effect. A therapeutic alliance is a necessary first step in cognitive ther-
apy, especially in counseling difficult-to-reach clients. Without a working alliance,
techniques applied will not be effective (Kazantzis et al., 2017). The relationship is
designed to be collaborative, in which therapist and client assume an equal share of
responsibility for addressing the client’s problems (DeRubeis et al., 2019). Thera-
pists must have a cognitive conceptualization of cases, be creative and active, be able
to improvise, be able to engage clients through a process of Socratic questioning,
and be knowledgeable and skilled in the use of cognitive and behavioral strategies
aimed at guiding clients in significant self-discoveries that will lead to change (Beck
& Weishaar, 2019).
Cognitive therapists are continuously active and deliberately interactive with
clients, helping clients frame their conclusions in the form of testable hypotheses.
The cognitive therapist functions as a catalyst and a guide who helps clients under-
stand how their beliefs and attitudes influence the way they feel and act. Clients are
expected to identify the distortions in their thinking, summarize important points
in the session, and collaboratively devise homework assignments that they agree
to carry out. Cognitive therapists emphasize the client’s role in self-discovery. The
assumption is that lasting changes in the client’s thinking and behavior will be most
likely to occur with the client’s initiative, understanding, awareness, and effort (Beck
& Weishaar, 2019; J. Beck, 2021).
Cognitive therapists identify specific, measurable goals and move directly into
the areas that are causing the most difficulty for clients. Typically, a therapist will
educate clients about the nature and course of their problem, about the process of
cognitive therapy, and how thoughts influence their emotions and behaviors. One
way of educating clients is through bibliotherapy, in which clients complete read-
ings that support and expand their understanding of cognitive therapy principles
and skills. These readings are assigned as an adjunct to therapy and are designed to
enhance the therapeutic process by providing an educational focus (Dattilio & Free-
man, 2007; Jacobs, 2008). Self-help books such as Mind Over Mood (Greenberger &
Padesky, 2016) also provide an educational focus.
Homework is often used as a part of cognitive therapy because practicing cog-
nitive-behavioral skills in real life facilitates more rapid and enduring gains. The
purpose of homework is not merely to teach clients new skills but also to enable
them to test their beliefs and to try out different behaviors in daily-life situations.
Homework is generally presented to clients as an experiment that serves to continue
work on issues addressed in a therapy session. Cognitive therapists realize that cli-
ents are more likely to complete homework if it is tailored to their needs, if they
participate in designing the homework, if they begin the homework in the therapy
session, and if they talk about potential problems in implementing the homework
(J. Beck, 2021). There are clear advantages to the therapist and the client working
346 C h a pt e r Te n

in a collaborative manner in negotiating mutually agreeable homework tasks. One

indicator of a good therapeutic alliance is whether homework is done and done well
(Kazantzis et al., 2017).

Applications of Cognitive Therapy

Cognitive therapy initially gained recognition as an approach to treating depres-
sion, but extensive research has been devoted to the study and treatment of many
other psychiatric disorders. The popularity of cognitive therapy is due in part to the
“strong empirical support for its theoretical framework and to the large number of
outcome studies with clinical populations” (Beck & Weishaar, 2019, p. 268). Hun-
dreds of research studies have confirmed the theoretical underpinnings of CT, and
hundreds of outcome trials have established its efficacy for a wide range of psychi-
atric disorders, psychological problems, and medical conditions with psychological
components (DeRubeis et al., 2019; Hofmann et al., 2012).
Cognitive therapy has been successfully used to treat depression, each of the
anxiety disorders, cannabis dependence, hypochondriasis, body dysmorphic disor-
der, eating disorders, anger, schizophrenia, insomnia, and chronic pain (Chambless
& Peterman, 2006; Dattilio & Kendall, 2007; Hofmann et al., 2012; Riskind, 2006);
suicidal behavior, borderline personality disorders, narcissistic personality disor-
ders, and schizophrenic disorders (Dattilio & Freeman, 2007); personality disorders
(Pretzer & Beck, 2006); substance abuse (Newman, 2006); medical illness (Dattilio &
Castaldo, 2001); crisis intervention (Dattilio & Freeman, 2007); couples and families
therapy (Dattilio, 1993, 1998, 2001, 2005, 2010; Dattilio & Padesky, 1990; Epstein,
2006); and child abusers, divorce counseling, skills training, and stress management
(Dattilio, 1998; Granvold, 1994; Reinecke et al., 2002). With children and adoles-
cents, CT has been shown to be effective in the treatment of depression and anxiety
disorders and more effective than medications for these problems. Clearly, cogni-
tive therapy programs have been designed for all ages and for a variety of client
populations.
Moreover, the effects of CT for depression and anxiety disorders seem to be
more enduring that the effects of other treatments, with the exception of behavior
therapy, which sometimes matches CT in duration of positive outcome. People who
get better using CT are less likely to relapse than those who improve with medica-
tion or most other psychotherapy approaches (DeRubeis et al., 2019; Hollon et al.,
2006).

Applying Cognitive Techniques Beck and Weishaar (2019) describe both cognitive
and behavioral methods that are part of the overall strategies used by cognitive
therapists. Cognitive methods focus on identifying and examining a client’s beliefs,
exploring the origins of these beliefs, and modifying them if the evidence does
not support these beliefs. Examples of behavioral techniques typically used by
cognitive therapists include activity scheduling, behavioral experiments, behavioral
activation, skills training, role playing, behavioral rehearsal, and exposure therapy.
Regardless of the nature of the specific problem, the cognitive therapist is mainly
interested in applying procedures that will assist individuals in making alternative
 C ogni ti ve B e havi or The r apy 347

interpretations of events in their daily living and behaving in ways that move them
closer to their goals and values.

Treatment Approaches The length and course of cognitive therapy varies greatly
and is determined by the therapy protocols used for specific diagnoses. For example,
cognitive therapy for depression generally lasts 16 to 20 sessions and begins with
behavioral activation. Activity has an antidepressant effect, especially when the
client engages in a mix of pleasurable, accomplished, and anti-avoidance activities.
Clients rate their moods in relation to the activities they do throughout the day,
and these observations are used as guides to find activities that provide a mood
boost in subsequent weeks. As depression begins to lift, the therapist introduces
additional skills such as thought records, which help clients identify negative
automatic thoughts and test them. When evidence does not support the automatic
thought, clients learn to generate alternative explanations that are less depressing.
When evidence does support the problematic thought, clients are helped to create
an action plan to solve the problem rather than ruminating on it (Greenberger
& Padesky, 2016). Before the end of treatment, underlying assumptions that put
clients at risk for relapse are examined such as perfectionistic assumptions (“If I
make a mistake, then I am worthless.”). These assumptions are tested with behavioral
experiments. For example, a perfectionistic client may intentionally make a mistake
doing a particular task and evaluate whether there is still some worth and value to
the outcome.
In contrast, cognitive therapy for panic disorder generally lasts only 6 to 12 ses-
sions and targets catastrophic beliefs about internal physical and mental sensations
(Clark et al., 1999). Clients are helped to identify the sensations that trigger a panic
attack and the catastrophic beliefs about these sensations. For example, a client may
think, “My heart is racing (sensation). That means I am having a heart attack (cata-
strophic belief).” The therapist helps the client generate an alternative hypothesis to
explain these feared sensations. For example, “A racing heart is not dangerous. It can
be caused by exercise, anxiety, caffeine, and many other things. The heart is a muscle,
and doctors recommend that you regularly raise your heart rate in exercise to keep
it healthy.” The therapist then guides the client to conduct a series of experiments
in a session in which the client creates the sensation and weighs evidence in support
of the catastrophic and alternative hypotheses. Once the client begins to believe the
alternative hypotheses in these experiments, which later are also done outside of
therapy, panic attacks are reduced or disappear.

Application to Family Therapy The cognitive-behavioral approach focuses on

cognitions, emotions, and behavior as they exert a mutual influence on one another
within family relationships to cause dysfunction. Cognitive theory emphasizes
schema, elsewhere defined as core beliefs, as a key aspect of the therapeutic process
(Beck, 1976; Beck & Haigh, 2014). Therapists help families restructure distorted
beliefs (or schema) in order to change dysfunctional behaviors. Some CT therapists
place a strong emphasis on examining cognitions among individual family members
as well as on what may be termed the “family schemata” (Dattilio, 1993, 1998, 2001,
2010). These jointly held beliefs about the family have formed as a result of years of
356 C h a pt e r Te n

Donald Meichenbaum feelings, and a running commentary. This childhood

Courtesy of Donald Meichenbaum, University of

(b. 1940) was born in New York experience contributed to Meichenbaum’s psycho-
City (the Bronx) and learned therapeutic approach of constructivist narrative
Waterloo, Department of Psychology
early to be “street smart” and therapy, in which clients tell their stories and de-
to be on the lookout for high- scribe what they did to “survive and cope.” Meichen-
risk situations. He attended baum’s recent work with returning service members
City College of New York and using iPod technology to bolster resilience is mod-
received his PhD in clinical eled on this approach. When therapy is successful,
psychology from the Univer- Meichenbaum ensures that clients take credit for
sity of Illinois. At the Univer- the changes they have achieved. As he observes, “I
Donald Meichenbaum
sity of Waterloo in Ontario, am at my therapeutic best when the clients I see are
Canada, he conducted research on the development one step ahead of me offering the observations or
of cognitive behavior therapy (CBT). He is one of the suggestions that I would otherwise offer” (Donald
founders of CBT, and in a survey of clinicians he was Meichenbaum, personal communication, October
voted one of the most influential therapists in the 20th 21, 2010).
century. He is the recipient of a Lifetime Achievement Meichenbaum has published extensively, includ-
Award from the Clinical Division of the American Psy- ing Cognitive Behavior Modification: An Integrative Ap-
chological Association for his work on suicide preven- proach (1977), Stress Inoculation Training (1985), Treat-
tion. In 1995 Meichenbaum retired from the University ment of Individuals With Anger-Control Problems and
of Waterloo to become the research director of the Aggressive Behaviors: A Clinical Handbook (2002), and
Melissa Institute for Violence Prevention, which is de- Roadmap to Resilience: A Guide for Military, Trauma
signed to “give science away” in order to reduce vio- Victims and Their Families (2012). He has lectured in
lence and to treat victims of violence. every state and in all provinces in Canada as well as
Meichenbaum attributes the origin of CBT to his internationally. He was a featured presenter at the Evo-
mother, who had a knack for telling stories about her lution of Psychotherapy conference in 2013 and the
daily activities that were peppered with her thoughts, Brief Therapy conference in 2014.

Donald Meichenbaum’s Cognitive Behavior Modification

Introduction
Donald Meichenbaum’s (2017) cognitive behavior modification (CBM) com-
bines some of the best elements of behavior therapy and cognitive therapy. A basic
premise of CBM is that clients must become aware of how they think, feel, and
behave and the impact they have on others before change can occur. Clients need
to be able to interrupt the scripted nature of their behavior so that they can evalu-
ate their behavior in various situations (Meichenbaum, 1993, 2007). Meichenbaum
(2017) believes the quality of the therapeutic relationship is critical to positive out-
comes, and he suggests working in a collaborative fashion with clients to develop
the skills necessary to achieve the treatment goals. Therapists do not view them-
selves as experts; instead, they continually seek feedback from their clients, supervi-
sors, and colleagues.
 C ogni ti ve B e havi or The r apy 357

This approach shares with REBT and Beck’s cognitive therapy the assumption
that distressing emotions are often the result of maladaptive thoughts. REBT is
more direct and confrontational in uncovering and disputing irrational thoughts,
whereas Meichenbaum’s self-instructional training focuses more on helping clients
become aware of their self-talk and the stories they tell about themselves. Both REBT
and CT focus on changing thinking processes, but Meichenbaum suggests that it
may be easier and more effective to change our behavior rather than our thinking.
Furthermore, our emotions and thinking are two sides of the same coin: the way we
feel can affect our way of thinking, just as how we think can influence how we feel.
The therapeutic process consists of teaching clients to make self-statements and
training clients to modify the instructions they give to themselves so that they can
cope more effectively with the problems they encounter. Cognitive restructuring
plays a central role in Meichenbaum’s (1977, 1993) self-instructional training. He
describes cognitive structure as the organizing aspect of thinking, which moni-
tors and directs the choice of thoughts through an “executive processor” that “holds
the blueprints of thinking” that determines when to continue, interrupt, or change
thinking. Together, therapist and client practice the self-instructions and the desir-
able behaviors in role-play situations that simulate problem situations in the client’s
daily life.

LO9 How Behavior Changes

Meichenbaum (1977) proposes that “behavior change occurs through a sequence of
mediating processes involving the interaction of inner speech, cognitive structures,
and behaviors and their resultant outcomes” (p. 218). He describes a three-phase
process of change in which those three aspects are interwoven and believes that
focusing on only one aspect will probably prove insufficient.
Phase 1: Self-observation. Clients learning how to observe their own behavior.
When clients begin therapy, their internal dialogue is characterized by neg-
ative self-statements and imagery. A critical factor is their willingness and
ability to listen to themselves. This process involves an increased sensitivity
to their thoughts, feelings, actions, physiological reactions, and ways of
reacting to others. If depressed clients hope to make constructive changes,
for example, they must first realize that they are not “victims” of negative
thoughts and feelings. Rather, they are actually contributing to their depres-
sion through the things they tell themselves. Although self-observation is
necessary if change is to occur, it is not sufficient for change.
Phase 2: Starting a new internal dialogue. As a result of the early client–therapist
contacts, clients learn to notice their maladaptive behaviors, and they
begin to see opportunities for adaptive behavioral alternatives. If clients
hope to change what they are telling themselves, they must initiate a new
behavioral chain, one that is incompatible with their maladaptive behav-
iors. Clients learn that psychological distress is a function of the interde-
pendence of cognitions, emotions, behaviors, and resultant consequences.
In therapy, clients learn to change their internal dialogue, which serves as
a guide to new behavior.
358 C h a pt e r Te n

Phase 3: Learning new skills. Clients learn to interrupt the downward spiral
of thinking, feeling, and behaving, and the therapist teaches clients more
adaptive ways of coping using the resources they bring to therapy. Clients
learn more effective coping skills, which are practiced in real-life situa-
tions. As they behave differently in situations, they typically get different
reactions from others. The stability of what they learn is greatly influenced
by what they say to themselves about their newly acquired behavior and its
consequences.

LO10 Stress Inoculation Training

A particular application of a coping skills program is teaching clients stress
management techniques by way of a strategy known as stress inoculation
training (SIT). Using cognitive techniques, Meichenbaum (1985, 2007, 2008)
has developed stress inoculation procedures that are a psychological and behav-
ioral analog to immunization on a biological level. Individuals are given oppor-
tunities to deal with relatively mild stress stimuli in successful ways, and they
gradually develop a tolerance for stronger stimuli. This training is based on
the assumption that we can affect our ability to cope with stress by modifying
our beliefs and self-statements about our performance in stressful situations.
Meichenbaum’s stress inoculation training is concerned with more than merely
teaching people specific coping skills. His program is designed to prepare clients
for intervention and motivate them to change, and it deals with issues such as
resistance and relapse.
Stress inoculation training is a combination of information giving, Socratic
discovery-oriented inquiry, cognitive restructuring, problem solving, relaxation
training, behavioral rehearsals, self-monitoring, self-instruction, self-reinforce-
ment, and modifying environmental situations (Meichenbaum, 2008). Collab-
orative goals are set that nurture hope, direct-action skills, and acceptance-based
coping skills. These coping skills are designed to be applied to both present prob-
lems and future difficulties. Clients are assisted in generalizing what they have
learned so they can use these skills in daily living, and relapse prevention strategies
are taught. Meichenbaum (2008) describes stress inoculation training as a com-
plex, multifaceted, cognitive-behavioral intervention that is both a preventive and
a treatment approach.
Clients can acquire more effective strategies in dealing with stressful situations
by learning how to modify their cognitive “set,” or core beliefs. The following proce-
dures are designed to teach these coping skills:
◆ Expose clients to anxiety-provoking situations by means of role playing
and imagery
◆ Require clients to evaluate their anxiety level
◆ Teach clients to become aware of the anxiety-provoking cognitions they
experience in stressful situations
◆ Help clients examine these thoughts by reevaluating their
self-statements
◆ Have clients note the level of anxiety following this reevaluation
 C ogni ti ve B e havi or The r apy 359

The Phases of Stress Inoculation Training Meichenbaum (2007, 2008) has

designed a three-stage model for stress inoculation training: (1) the conceptual-
educational phase, (2) the skills acquisition and consolidation phase, and (3) the
application and follow-through phase.
During the conceptual-educational phase, the primary focus is on creating a ther-
apeutic alliance with clients. This is done by helping clients gain a better under-
standing of the nature of stress and reconceptualizing it in social-interactive terms.
Initially, clients are provided with a conceptual framework in simple terms designed
to educate them about ways of responding to a variety of stressful situations. They
learn about the role cognitions and emotions play in creating and maintaining
stress through didactic presentations, by curious questioning, and by a process of
guided self-discovery. A collaborative relationship is created during this early phase,
and together they rethink the stress concerns clients bring to understand the nature
of the problem.
Clients often begin treatment feeling that they are victims of external circum-
stances, thoughts, feelings, and behaviors over which they have no control. As a way
to understand the subjective world of clients, the therapist generally elicits stories
that clients tell themselves. Training includes teaching clients to become aware of
their own role in creating their stress and their life stories. They acquire this aware-
ness by systematically observing the statements they make internally as well as by
monitoring the maladaptive behaviors that flow from this inner dialogue. Such self-
monitoring continues throughout all the phases. As is true in cognitive therapy,
clients typically keep an open-ended diary in which they systematically monitor
and record their specific thoughts, feelings, and behaviors. In teaching these coping
skills, therapists strive to be flexible in their use of techniques and to be sensitive to
the individual, cultural, and situational circumstances of their clients.
During the skills acquisition and consolidation phase, the focus is on giving clients a
variety of behavioral and cognitive coping skills to apply to stressful situations. This
phase involves direct actions, such as gathering information about their fears, learn-
ing specifically what situations bring about stress, arranging for ways to lessen the
stress by doing something different, and learning methods of physical and psycholog-
ical relaxation. The training involves cognitive coping; clients are taught that adaptive
and maladaptive behaviors are linked to their inner dialogue. Through this training,
clients acquire and rehearse a new set of self-statements. Meichenbaum (1986) pro-
vides some examples of coping statements that are rehearsed in this phase of SIT:
◆ “How can I prepare for a stressor?” (“What do I have to do? Can I
develop a plan to deal with the stress?”)
◆ “How can I confront and deal with what is stressing me?” (“What are
some ways I can handle a stressor? How can I meet this challenge?”)
◆ “How can I cope with feeling overwhelmed?” (“What can I do right
now? How can I keep my fears in check?”)
◆ “How can I make reinforcing self-statements?” (“How can I give myself
credit?”)
Clients also are exposed to various behavioral interventions, such as relaxation
training, social skills training, time-management instruction, and self-instruc-
tional training. They are helped to make lifestyle changes by reevaluating priorities,
360 C h a pt e r Te n

developing support systems, and taking direct action to alter stressful situations.
Through teaching, demonstration, and guided practice, clients learn the skills of
progressive relaxation and practice them regularly to decrease arousal due to stress.
During the application and follow-through phase, the focus is on carefully arranging
for transfer and maintenance of change from the therapeutic situation to everyday
life. Clients practice their new self-statements and apply their new skills to everyday
life. To consolidate the lessons learned in the training sessions, clients participate in
a variety of activities, including imagery and behavior rehearsal, role playing, model-
ing, and graded in vivo exposure. Once clients have become proficient in cognitive
and behavioral coping skills, they practice behavioral assignments, which become
increasingly demanding. They are asked to write down the homework assignments
they are willing to complete. The outcomes of these assignments are carefully
checked at subsequent meetings, and if clients do not follow through with them,
therapist and client collaboratively consider the reasons for the failure.
Relapse prevention, which consists of procedures for dealing with the inevi-
table setbacks clients are likely to experience as they apply what they are learning to
daily life, is taught at this stage (Marlatt & Donovan, 2007). Clients learn to view any
lapses that occur as “learning opportunities” rather than as “catastrophic failures.”
Clients explore a variety of possible high-risk, stressful situations that they may reex-
perience. In a collaborative fashion with the therapist, and with other clients in a
group, clients rehearse and practice applying the skills they have learned to maintain
the gains they have made. Follow-up and booster sessions typically take place at 3-,
6-, and 12-month periods as an incentive for clients to continue practicing and refin-
ing their coping skills. SIT can be considered part of an ongoing stress management
program that extends the benefits of training into the future.
Stress inoculation training has potentially useful applications for a wide variety
of problems and clients and for both remediation and prevention. Clinical appli-
cations of SIT are individually tailored to specific target populations and include
anger control, pain control, anxiety management, assertion training, improving
creative thinking, treating depression, dealing with health problems, and preparing
for surgery. Stress inoculation training has been employed with medical patients
and with psychiatric patients. Meichenbaum (2007) contends that the flexibility of
the SIT format has contributed to its robust effectiveness. SIT has been successfully
used with children, adolescents, and adults who have anger problems, anxiety dis-
orders, phobias, social incompetence, addictions, alcoholism, sexual dysfunctions,
social withdrawal, or posttraumatic stress disorder (PTSD), including use with vet-
erans who experience combat-related PTSD (Meichenbaum, 1993, 1994a, 1994b,
2007, 2008, 2012).

A Cognitive Narrative Approach to Cognitive Behavior Therapy

Meichenbaum (2015) has embraced a cognitive narrative perspective, which
focuses on the plots, characters, and themes in the stories people tell about them-
selves and others regarding significant events in their lives. Therapists elicit stories
from their clients that are explored in the therapy process. This approach begins
with the assumption that there are multiple realities. One of the therapeutic tasks
is to help clients appreciate how they construct their realities and how they author
 C ogni ti ve B e havi or The r apy 361

their own stories (see Chapter 13). Meichenbaum claims that we are all “story tell-
ers” and that we should be aware of the stories we tell ourselves and others. For
example, some clients might see themselves as “prisoners of the past” or as “stub-
born victims.” These phrases are not idle metaphors; they are the organizing sche-
mas that color the ways individuals view themselves, their world, and their future.
Therapists help clients appreciate how they construct reality and examine the
implications and conclusions clients draw from their stories. Telling the “rest of
the story”—what they did to survive and cope—bolsters clients’ strengths and helps
them develop resilient-engendering behaviors. In this way, clients can move from
being “stubborn victims” to becoming “tenacious survivors” and perhaps “impres-
sive thrivers.” Meichenbaum (2012) works in a collaborative fashion with clients
to develop the coping skills necessary to achieve these treatment goals. He uses a
Socratic discovery-oriented approach and the art of questioning to assist clients in
reaching their goals.
Meichenbaum (1997) uses these questions to evaluate the outcomes of therapy:
◆ Are clients now able to tell a new story about themselves and the
world?
◆ Do clients now use more positive metaphors to describe themselves?
◆ Are clients able to predict high-risk situations and employ coping skills
in dealing with emerging problems?
◆ Are clients able to take credit for the changes they have been able to
bring about?
In successful therapy clients develop their own voices, take pride in what they
have accomplished, and take ownership of the changes they are bringing about. In
short, clients become their own therapists and take the therapist’s voice with them.

LO1 Cognitive Behavior Therapy From a Multicultural

Perspective
Strengths From a Diversity Perspective
Cognitive-behavioral approaches have several strengths in working with individu-
als from diverse cultural, ethnic, and racial backgrounds. Asking clients during the
intake process to share the strengths and challenges of their cultural, racial, and
ethnic identity is an effective way to begin the discovery process. It is critical that
counselors are aware of their own values, beliefs, and biases and that they respect
clients’ core cultural values and belief systems (Shaw & Green, 2022). If therapists
understand the core values of their culturally diverse clients, they can help clients
explore these values and gain a full awareness of their conflicting feelings. Then the
client and the therapist can work together to modify selected beliefs and practices.
Cognitive-behavioral approaches can be modified to incorporate a collectivistic
rather than an individualistic perspective (Sue et al., 2022). Cognitive behavior ther-
apy tends to be culturally sensitive because it uses the individual’s belief system, or
worldview, as part of the method of self-exploration. We cannot ethically engage
clients without understanding their worldview.
362 C h a pt e r Te n

Because counselors with a cognitive-behavioral orientation function as teach-

ers, clients are actively involved in learning skills to deal with the problems of living.
In speaking with colleagues who work with culturally diverse populations, I have
learned that their clients tend to appreciate the emphasis on cognition and action,
as well as the emphasis on relationship issues. The collaborative approach of CBT
offers clients a structured therapy program, yet the therapist still makes every effort
to enlist clients’ active cooperation and participation. Psychotherapy is essentially a
psychoeducational process, and cognitive and behavioral methods can facilitate this
learning. The psychoeducational focus of CBT is a clear strength that can be applied
to many clinical problems and used effectively in many settings with diverse client
populations. A strength of CBT is integrating assessment of client beliefs, emotional
responses, and behavioral choices throughout therapy, which communicates respect
for clients’ viewpoints regarding their progress. Often individuals from diverse cul-
tures are erased in this society and made invisible. The counselor has an opportunity
to validate their clients by hearing them, seeing them, and respecting their life story.
Hays (2009) asserts there is an “almost perfect fit” between cognitive behav-
ior therapy and multicultural therapy because these perspectives share common
assumptions that make integration possible. Aspects that contribute to an integra-
tive framework include the following:
◆ Interventions are tailored to the unique needs and strengths of the
individual.
◆ Clients are empowered by learning specific skills they can apply in daily
life (CBT) and by the emphasis on cultural influences that contribute
to clients’ uniqueness (multicultural therapy).
◆ Inner resources and strengths of clients are activated to bring about
change.
◆ Clients make changes that minimize stressors, increase personal
strengths and supports, and establish skills for dealing more effectively
with their physical and social (cultural) environments.

Shortcomings From a Diversity Perspective

Exploring values and core beliefs plays an important role in all of the cognitive-
behavioral approaches, and it is crucial for therapists to have some understanding
of the cultural background of clients and to be sensitive to their struggles. REBT
therapists would do well to use caution in their choice of language and expression
when confronting clients about their beliefs and behaviors. REBT suggests that the
therapist’s job is to help clients critically examine long-standing cultural values that
result in dysfunctional emotions or behaviors, but a potential limitation of REBT
is its negative view of dependency. It would be useful for therapists to do their per-
sonal homework and explore the research on interdependence and the importance
of the collective in our global community. Many cultures view interdependence
as necessary to good mental health. Clients with long-cherished cultural values
 C ogni ti ve B e havi or The r apy 363

pertaining to interdependence may not respond favorably to forceful methods of

persuasion toward independence. Cultural beliefs must be respected even though
the counselor may be unfamiliar with the practices and belief system of their cli-
ents. Skillful REBT practitioners carefully monitor their manner, style, and choice
of words and communicate whenever possible in language that is congruent with
the client’s culture.
Hays (2009) suggests that therapists avoid challenging the core cultural
beliefs of clients unless the client is clearly open to this. By emphasizing col-
laboration over confrontation, as the cognitive-behavioral approaches do, the
therapist can avoid seeming to be disrespectful. Hays recommends drawing on
the client’s culturally related strengths in developing helpful ways of thinking
to replace unhelpful cognitions. For example, consider an Asian American cli-
ent, Sung, from a culture that traditionally stresses values such as doing one’s
best, cooperation, interdependence, and working hard. Sung may feel that she is
bringing shame to her family if she is going through a divorce, and she may feel
guilt if she perceives that she is not living up to the expectations and standards
set for her by her family and her community. Sung can be helped to consider
how her cultural values of cooperation and interdependence may enable her
family to support her during a difficult divorce. The rules for Sung are likely
to be different from the rules for a male member of her culture. The counselor
could assist Sung in understanding and exploring how both her gender and
her culture are factors to consider in her situation. If Sung is confronted too
quickly on living by the expectations or rules of others, the results are likely to
be counterproductive. Sung might even leave counseling if she feels that she is
not being understood or being asked to disregard her cultural identity in order
to fit into a more Western view of health and wellness.
The emphasis of CBT on assertiveness, independence, verbal ability, rationality,
cognition, and behavioral change may limit its use in cultures that value subtle com-
munication over assertiveness, interdependence over personal independence, listen-
ing and observing over talking, and acceptance over behavior change (Hays, 2009).
In CBT the focus is on the present, which can result in the therapist failing to recog-
nize the role of the past in a client’s development. Cognitive-behavioral assessments
involve the investigation of a client’s personal history. If the therapist is unaware of a
client’s cultural beliefs, which are rooted in the past, the therapist may have difficulty
interpreting the client’s personal experiences accurately.
Another limitation of CBT from a multicultural perspective involves its indi-
vidualistic orientation. For clients from certain cultures, a collectivistic orientation
implies considering the family and community context when assessing and defining
problems (Sue et al., 2022). An inexperienced therapist may overemphasize cognitive
restructuring to the neglect of environmental interventions. Hays (2009) points out
that these potential limitations do not preclude the integration of CBT and multi-
cultural counseling. Instead, being aware of these limitations “presents opportuni-
ties for rethinking, refining, adapting and increasing the relevance and effectiveness
of psychotherapy” (p. 356).
 C ogni ti ve B e havi or The r apy 367

Gwen: Maybe I could make a list of my assumptions become more adept at catching and disputing them.
and some of the negative thoughts that result from In our next session, we discuss her homework and
them. Then I could try to list some facts that coun- evaluate the response it has had on her level of anxiety
ter those negative thoughts. in the workplace.

Therapist: I am glad you are willing to try to find some Questions for Reflection
facts to work with. I think this will help you to be
◆ What role, if any, does Gwen play in her experi-
less anxious.
ences of isolation?
Gwen: And I will try to be more friendly at work. ◆ How does the therapist intervene to assist Gwen in
looking for evidence for her negative thinking?
Therapist: Isolating yourself doesn’t seem to be work- ◆ How would you encourage Gwen to complete her
ing, so let’s see how you feel when you talk with homework assignment?
your coworkers. ◆ How would you respond if you knew that Gwen
I give Gwen a journal to record her homework ex- was being subjected to racism and rejection in the
periments and how doing a new behavior affects her office? How would CBT help her in that case?
anxiety level. I encourage her to develop awareness of ◆ What additional CBT technique might you use if
the automatic thoughts that occur to her so she can you were counseling Gwen?

Summary and Evaluation

Summary
REBT has evolved into a comprehensive and integrative approach that emphasizes
thinking, assessing, deciding, doing, and compassion. This approach is based on the
premise of the interconnectedness of thinking, feeling, and behaving and is both scien-
tific and humanistic at its core. Therapy can begin with clients’ problematic behaviors
and emotions, and clients can learn to dispute the thoughts that directly create them. To
transform any self-defeating beliefs that are reinforced by a process of self-indoctrina-
tion, REBT therapists employ active and directive techniques such as teaching, sugges-
tion, persuasion, and homework assignments, and they encourage clients to substitute
a rational belief system for an irrational one. The main strategies of REBT involve chal-
lenging and replacing dysfunctional beliefs with rational beliefs (DiGiuseppe & Doyle,
2019). Therapists demonstrate how and why dysfunctional beliefs lead to negative emo-
tional and behavioral results. They teach clients how to dispute self-defeating beliefs
and behaviors that might occur in the future. REBT emphasizes the benefit of taking
action—doing something about the insights one gains in therapy. Change comes about
mainly by practicing new behaviors that replace old and ineffective ones. Unconditional
self-acceptance, unconditional other-acceptance, and unconditional life-acceptance,
along with daily gratitude, are strongly encouraged. Rational emotive behavior thera-
pists are typically eclectic in selecting therapeutic strategies. They have the latitude to
develop their own personal style and to exercise creativity. They are not bound by fixed
techniques for particular problems. REBT concepts and techniques can be integrated
into other psychotherapeutic approaches.
368 C h a pt e r Te n

Cognitive therapists also practice from an integrative stance, using many meth-
ods to help clients learn to identify links between thoughts, emotions, behaviors,
physiology, and situations. Some defining characteristics of cognitive therapy are
that the client is active and works as a partner with the therapist; the therapist is
active and directive; the therapy is structured and psychoeducational; an agenda
provides focus for each session; and therapy is time limited (Freeman & Freeman,
2016). The working alliance is given special importance in cognitive therapy as a
way of forming a collaborative partnership. Although rapport in the client–therapist
relationship is viewed as helpful by Beck, it is not considered sufficient for therapy
success. In cognitive therapy, it is presumed that clients are helped by the skillful
use of a range of cognitive and behavioral interventions and by therapists engaging
clients’ willingness to perform homework assignments between sessions. Cognitive
therapists are expected to be able to conceptualize client problems in ways that link
personal client experiences to the evidence-based treatments that are most likely to
be successful.
All of the cognitive-behavioral approaches stress the importance of links
between cognitive processes, emotions, and behavior. It is assumed that how people
feel and what they actually do is largely influenced by their subjective assessment and
interpretation of situations. Because this appraisal of life situations is influenced
by beliefs, attitudes, assumptions, and internal dialogue, such cognitions become a
major focus of therapy.

LO12 Contributions of the Cognitive-Behavioral Approaches

Most of the therapies discussed in this book can be considered “cognitive” in a
general sense because they have the aim of changing clients’ subjective views of
themselves and the world. The cognitive-behavioral approaches have developed sys-
tematic and sophisticated forms of psychotherapy that focus on testing assump-
tions and beliefs and teaching clients the coping skills needed to deal with their
problems. A basic principle of CBT is that emotional and behavioral changes can be
achieved by changing cognitions, just as cognitive change can be altered by actions
and emotions (Freeman & Freeman, 2016).
Ellis’s REBT and Beck’s CT represent the most systematic applications of cog-
nitive behavior therapy. Both REBT and CT are based on a wide range of cogni-
tive-behavioral techniques and follow a defined plan of action; they can often be
relatively brief and structured treatments in keeping with the spirit of maximiz-
ing effectiveness and efficiency, cost effectiveness, and evidence-based practice
(DiGiuseppe & Doyle, 2019). The psychoeducational aspect of CBT and REBT is a
clear strength that can be applied to many clinical problems and used effectively in
many settings with diverse client populations (Ellis & Ellis, 2019a). The evidence
basis in support of CBT therapies often makes them the “gold standard” by which
therapy effectiveness is judged. A body of research supports the efficacy of REBT
(DiGiuseppe & Doyle, 2019).

Ellis’s REBT One of the strengths of REBT is the focus on teaching clients ways to
carry on their own therapy without the direct intervention of a therapist. I particularly
like the emphasis that REBT puts on supplementary and psychoeducational
 C ogni ti ve B e havi or The r apy 369

approaches such as listening to tapes, reading self-help books, keeping a record

of what they are doing and thinking, and carrying out homework assignments. In
this way clients can further the process of change in themselves without becoming
excessively dependent on a therapist.

Beck’s Cognitive Therapy Beck’s key concepts share similarities with REBT but
differ in being empirically rather than philosophically derived, the processes by which
therapy proceeds, and the formulation and treatment for different disorders. Beck
made pioneering efforts in the treatment of anxiety, phobias, and depression. Beck
demonstrated that a structured therapy that is present centered and problem oriented
can be very effective in treating depression and anxiety in a relatively short time. Today,
empirically validated treatments for both anxiety and depression have revolutionized
therapeutic practice; research has demonstrated the efficacy of cognitive therapy for
a variety of problems (DeRubeis et al., 2019; Hofmann et al., 2012). Beck developed
specific cognitive procedures to help depressive clients evaluate their assumptions and
beliefs and to create a new cognitive perspective that can lead to optimism and changed
behavior. Research demonstrates that the effects of cognitive therapy on depression
and hopelessness are usually maintained for at least one year after treatment.
Cognitive therapy has been applied to a wide range of clinical populations that Beck
did not originally believe were appropriate for this model, including treatment for
posttraumatic stress disorder, schizophrenia, delusional disorders, bipolar disorder,
and various personality disorders (Hofmann et al., 2012). The credibility of the cognitive
model grows out of the fact that many of its propositions have been empirically tested.

Padesky and Mooney’s Strengths-Based CBT Beck’s CT has been further

expanded with Padesky and Mooney’s strengths-based CBT approach. In addition
to incorporating strengths at each phase of treatment, SB-CBT has successfully
incorporated a wide range of modalities including imagery, metaphor, stories,
and kinesthetic body experiences into the broad repertoire of CBT interventions.
SB-CBT also provides models that extend CBT from evidence-based treatment of
client problems to evidence-based models for developing positive qualities and
client strengths. Instead of focusing solely on testing existing beliefs, SB-CBT offers
systematic methods for helping clients construct new beliefs and behaviors that
help realize their goals of “how they would like to be.”

Meichenbaum’s Cognitive Behavior Modification Meichenbaum’s work in self-

instruction and stress inoculation training has been applied successfully to a variety
of client populations and specific problems. Of special note is his contribution
to understanding how stress is largely self-induced through inner dialogue.
Meichenbaum’s integration of the cognitive narrative perspective is a key strength
of his therapy style. He is able to combine elements of the postmodern interest in
stories clients tell with assisting clients in changing their cognitions, feelings, and
behaviors by drawing on a cognitive-behavioral conceptual framework.

A contribution of all of the cognitive-behavioral approaches is the emphasis on put-

ting newly acquired insights into action. Homework assignments, which are col-
laboratively designed by therapist and client, are well suited to enabling clients to
370 C h a pt e r Te n

practice new behaviors and assisting them in the process of learning more effective
coping skills. It is important that collaboratively created homework be a natural
outgrowth of what is taking place in the therapy session. Ellis’s REBT, Beck’s cog-
nitive therapy, Padesky and Mooney’s strengths-based CBT, and Meichenbaum’s
stress inoculation training all place special emphasis on practicing new skills both
in therapy and in daily life, and homework is a key part of the learning process. Cli-
ents learn how to generalize coping skills to various problem situations and acquire
relapse prevention strategies to ensure that their gains are consolidated.
A major contribution made by Ellis, the Becks, Padesky and Mooney, and Meich-
enbaum is the demystification of the therapy process. The cognitive-behavioral
approaches are based on an educational model that stresses a working alliance
between therapist and client. The models encourage self-help, provide for continu-
ous feedback from the client on how well treatment strategies are working, and pro-
vide a structure and direction to the therapy process that allows for evaluation of
outcomes. Clients are active, informed, and responsible for the direction of therapy
because they are partners in the enterprise.

LO13 Limitations and Criticisms of the Cognitive-Behavioral

Approaches
Some critics have charged that the cognitive-behavioral approaches focus only lim-
ited attention on the role of emotions in treatment. These therapies were originally
developed to help people already experiencing extreme emotional arousal, and this
perception may be an artifact of that fact. When clients are severely depressed or
highly anxious, it is beneficial to focus less directly on these emotions per se and
more on the balancing roles of belief and behavior. When CBT therapists work with
clients who keep emotion at arms’ length, they use imagery, role play, and emotional
expression to elicit emotion and bring it into therapy. Although CBT therapists may
not talk about emotion as frequently as some other therapies, CBT is almost always
dealing directly with emotion and its consequences. Some potential limitations of
the various CBT approaches follow.

Ellis’s REBT I question the REBT assumption that exploring the past is ineffective
in helping clients change faulty thinking and behavior. From my perspective,
exploring past childhood experiences can have a great deal of therapeutic power
if the discussion is connected to present functioning. In fact, Albert Ellis would
(and Debbie Joffe Ellis continues to) listen to past childhood experiences in the
initial session, or during early sessions. These stories can be valuable as sources of
irrational beliefs still held by the client in the here and now. Attention would then
very quickly move to exploring, disputing, and replacing these beliefs.
Another potential limitation of ineffective or inexperienced REBT therapists
involves the misuse of the therapist’s power by imposing ideas of what constitutes
rational thinking. Due to the active and directive nature of this approach, it is partic-
ularly important for practitioners to avoid imposing their own philosophy of life on
their clients. The skillful REBT therapist clarifies the REBT definitions of rational
versus irrational thoughts and healthy negative emotions versus unhealthy negative
emotions (Ellis & Ellis, 2019a).
 C ogni ti ve B e havi or The r apy 371

Some clients may have trouble with a confrontational style of REBT, especially
if a strong therapeutic alliance has not been established. It is well to underscore that
REBT can be effective when practiced in a style different from the bold manner that
Albert Ellis frequently displayed. Albert Ellis often expressed the notion that ther-
apists do not need to emulate his style to effectively incorporate REBT into their
own repertoire of interventions. Debbie Joffe Ellis, who continues to teach and write
about the “Ellis” REBT approach, enthusiastically encourages therapists to adhere to
REBT tenets and principles in their own authentic manner and style (D. Ellis, 2014).

Beck’s Cognitive Therapy Cognitive therapy has been criticized for focusing too
much on the power of positive thinking; being too superficial and simplistic; denying
the importance of the client’s past; being too technique oriented; failing to use the
therapeutic relationship; working only on eliminating symptoms and failing to
explore the underlying causes of difficulties; ignoring the role of unconscious factors;
and neglecting the role of feelings (Freeman & Dattilio, 1992; Weishaar, 1993).
Although the cognitive therapist is straightforward and looks for simple rather
than complex solutions, this does not imply that the practice of cognitive therapy
is simple. Cognitive therapists do not pursue positive thinking but rather thinking
based on actual experiences. Cognitive therapists do not believe the unconscious is
difficult to access. With direct and guided questioning, clients can identify assump-
tions and beliefs that exist below awareness and also link these beliefs to behavioral
patterns and emotional reactions. They also recognize that clients’ current problems
are often a product of earlier life experiences, and they may explore with clients the
ways their past is presently influencing them.

Padesky and Mooney’s Strengths-Based CBT The biggest criticism of

strengths-based CBT is that the evidence base supporting the approach is still in its
infancy. Some CBT therapists question whether the addition of client strengths adds
anything to CBT’s effectiveness. Studies currently underway in Europe and the United
Kingdom are testing this hypothesis, especially to see whether a strengths and resilience
focus increases the enduring effects of therapy. Additional research is necessary to
examine whether construction of new beliefs and behaviors is more effective than
examining current beliefs and behaviors in the treatment of chronic problems.

Meichenbaum’s Cognitive Behavior Modification Meichenbaum is very

charismatic in his workshop presentations. Much of the success of his approach may
be based on his level of caring and his creativity in implementing CBT interventions.
Practitioners without his wit, energy, personal flair, and direct therapeutic style may not
get the same results even though they follow his treatment protocol. This emphasizes
the importance for therapists to develop their own unique therapeutic style.

A potential limitation of any of the cognitive-behavioral approaches is the therapist’s

level of personal development, training, knowledge, skill, perceptiveness, and ability
to establish a therapeutic alliance. Although this is true of all therapeutic approaches,
it is especially true for CBT practitioners because they tend to be active, highly struc-
tured, offer clients useful information, and teach life skills. Who the therapist is
as a person is as important as knowledge and skills. Therapists teach their clients
372 C h a pt e r Te n

through what they model. Debbie Joffe Ellis (2014) encourages practitioners to strive
to be mindful, to think about their thinking, and to do their best to practice what
they preach. In so doing, they can be healthy models for their clients and others and
experience greater authenticity and satisfaction in their own lives as well.

Self-Reflection and Discussion Questions

1. In most CBT models, the therapist functions in many ways as a teacher.
How does a psychoeducational model fit with your way of practicing
counseling?
2. Cognitive-behavioral practitioners use a brief, active, directive, collab-
orative, present-focused, didactic, psychoeducational model of therapy
that relies on empirical validation of its concepts and techniques. What
potential advantages do you see of this focus? Any disadvantages?
3. Ellis, Beck, Padesky, and Meichenbaum are all in the cognitive-behavioral
camp, yet they all have distinctive approaches to counseling. Which of
these approaches are you most drawn to and why?
4. CBT provides for use of a wide range of techniques. What techniques
might you apply to yourself? What techniques are you likely to incor-
porate in your work with clients?
5. The cognitive-behavioral therapies are among the most popular with
today’s practitioners. What do you think accounts for the increased
interest in CBT?

Where to Go From Here

DVDs relevant to this chapter offered by the American Psychological Association
from their Systems of Psychotherapy Video Series include the following:
Beck, J. (2005). Cognitive Therapy
Ellis, D. J. (2014). Rational Emotive Behavior Therapy
Meichenbaum, D. (2007). Cognitive Behavioral Therapy With Donald
Meichenbaum
Vernon, A. (2010). Rational Emotive Behavior Therapy Over Time
Dobson, K. S. (2010). Cognitive Therapy Over Time
Persons, J. (2006). Cognitive-Behavior Therapy
Dobson, K. S. (2008). Cognitive-Behavioral Therapy for Perfectionism Over Time
Dobson, K. S. (2011). Cognitive-Behavioral Therapy Strategies
Audio recordings of workshops and videos relevant to this chapter that
illustrate CBT protocols and methods in practice are also offered by Padesky at
www. padesky.com:
Padesky, C. A. (1993). Cognitive Therapy for Panic Disorder
Padesky, C. A. (1996). Guided Discovery Using Socratic Dialogue