What distinguishes both behavior and cognitive therapies from traditional psychological treatment is their focus on the origin of a particular disorder and how best to treat it. Typically, behavior and cognitive therapies view disorders arising from an individual's genetics and learning history.
Treatment relies on changing an individual's environment, thus altering the learning repertoire. Environment, broadly defined, consists of not only the external environment, but also the internal one. The internal environment includes not only emotions and physical sensations, but also thinking. All of these factors contribute to both adaptive and maladaptive patterns of behavior that are either desirable or undesirable to the individual.
With behavior and cognitive therapies, the patient is an agent of change who takes an active role in their treatment. The patient is encouraged to act and practice desirable forms of behavior both in vivo and in session.
Put simply, talk without action is of limited use in behavior and cognitive therapies. Data may also be collected to aid in progress towards stated goals.
Depending on the disorder and reason for referral, some methods are more appropriate to use than others.
In contrast, traditional forms of psychotherapy, to varying degrees, rely almost exclusively on more passive forms of treatment.
Psychodynamic therapies, in general, attribute disorders to factors that are not readily accessible to the patient and clinician. These latent factors are believed to reside somewhere within a patient's unconscious, an area of the mind that cannot be observed or measured. Instead, these factors can only be supposed to exist and hints of their operations gleaned from overt behavior. For instance, compulsive hand washing is viewed as a psychological metaphor for unresolved guilt. Depression is the result of anger turned inward. External symptoms are nothing more than emanations from the unconscious.
The focus of treatment, therefore, cannot be on the overt symptoms, but the internal, unconscious sources of conflict. The idea is to get at the source of the disorder, not the superficial symptoms. Considering that neither the patient nor clinician can actively alter these unconscious factors, they can only come to understand them. Understanding the disorder takes the forms of talking about life experiences that are believed to have contributed to the development of these unconscious factors. In this way, understanding is the goal of treatment, not alleviation of suffering or enhancement of functioning.
As you can see, there are substantial differences between these forms of treatment. These differences are not merely reserved to the use of specific techniques. Instead, the major difference that transcends technique is case conceptualization. All good psychologists develop working relationships with their clientele. All good psychologists interact with their patients to form and maintain a rapport. It is case conceptualization that differentiates forms of therapy and orientation.
Case conceptualization is how the clinician views the etiology (cause) of the disorder and how to treat it. During the course of treatment, techniques may change, but the essential case conceptualization stays the same. A behavioral or cognitive case conceptualization includes (Persons, 1989):
- Setting a primary therapeutic goal of alleviating, solving, or eliminating overt clinical problems and symptoms. As part of the emphasis on solving overt problems, behavior and cognitive therapists work with patients to measure these problems, whenever possible, in concrete, objective terms so that the outcome of the therapy can be monitored and assessed.
- Adopting an active, problem-solving approach to clinical problems.
- Focusing on the here-and-now rather than the past. An effective cognitive and behavior therapist obtains a good family and social history. This information is important for several reasons, particularly in developing a useful case conceptualization. The behavior and cognitive therapist may even spend some time working on past events, but this is generally done in the context of helping the patient solve here-and-now difficulties.
- Building a collaborative patient-therapist relationship. The behavior and cognitive therapist does not solve the patient's problems; the therapist works with the patient to develop solutions that are helpful to the patient.
- Maintaining an empirical attitude, both with regard to the choice of the therapy modality itself (what does the outcome literature say about which treatment approach is most effective for the problems presented by this patient?) and with regard to the conceptualization and interventions used to treat each particular patient.
- Relying on cognitive and learning theories that view clinical problems as understandable within a framework of reciprocally connected behaviors, cognition, and affects that are activated by environmental events, including, of course, interpersonal events.
- Assigning homework. The key role of homework in behavior and cognitive therapy draws directly on the view of therapy as a learning experience in which the patient learns new perceptions and skills.
One of the biggest misconceptions of behavior and cognitive therapies is that the patient sits in front of a rigid clinician and is reserved to filling out forms and data sheets with no regard to the human interaction. This unfortunate stereotype also suggests that the behavior and cognitive therapist is either ill equipped or not skilled to deal with deep, existential, and personal issues. Nothing can be further from the truth.
Such an inaccurate portrayal is the result of both ignorance and arrogance. The fact is that behavior and cognitive therapists can treat a host of presenting issues. However, evidence in the literature does suggest that certain disorders are treated better by certain therapies. The question, then, has been asked, "what works and for whom (Roth and Fonagy, 1996)?" Though there is no definite answer to this question at this juncture, what can be stated is that certain disorders are more amenable to behavior and cognitive therapies than others if treatment is defined as symptom reduction and prevention and empirically based treatments are employed. In some cases, if not all, treatment may be deemed successful at this point.
The best advice for any patient is to work with a clinician who meets their needs, which may entail, "shopping around." For behavior and cognitive therapy, the use of behavioral and cognitive techniques is not equivalent to the practice of behavior, cognitive, or cognitive-behavioral therapy! The research that demonstrates efficacy and effectiveness of behavior, cognitive, or cognitive-behavioral therapy is not based on haphazard use of techniques, but through case conceptualization and manualized treatment where available. The proper use of techniques, case conceptualization, and application requires years of study, internship, and supervision with like-minded psychologists.
Don't be afraid to ask questions about education and training and what qualifies a clinician to practice a proposed therapy. In the long run, you will be glad that you did. Being a licensed psychologist does not qualify a clinician to vacillate between modes of treatment. As in medicine, specialization requires specialized training. Psychological practice is no different. Attending a weekend workshop does not qualify a clinician as either specially trained or an expert in treating a particular disorder.
References
Roth, A. & Fonagy, P. (1996). What Works for Whom? A Critical Review of Psychotherapy Research. New York, Guilford Press.
