Research Paper: Tom Shulich ("Coltish Hum

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[. . .] The Therapist's Role

Behavior therapy assumes a learning model of psychopathology. The central idea of this type of therapy is that psychological distress results from maladaptive behaviors that one has learned and that these behaviors can be unlearned or replaced with new adaptive behaviors. In BT, the therapist plays the role first of diagnostician, determining what behaviors are the source of the problem, then as a teacher or coach who suggests exercises the patient is asked to practice in order to modify the behavior.

Cognitive therapy assumes a rational model of psychopathology. The patient has incorporated irrational or self-defeating beliefs that are in fact at odds with objective reality. They make their situation out worse than it actually is, if only they could think about their predicament rationally. The therapist plays the role of instructor or wise man. The therapist by asking questions, will direct the client to rethink those situations that trouble them. The situation may remain objectively the same after the course of treatment, but the patient comes out of the therapy with a new outlook. Things that previously disturbed and upset the person will cease to feel threatening as the person cultivates a broader, more logical perspective.

Neither BT nor RET requires the therapist to develop a close personal relationship with the client. Psychoanalytic concepts such as transference, in which the patient works out their emotional issues with significant others by projecting them onto the therapist, have no place in these therapies. In both therapies, the therapist is expected to diagnose the problem and come up with a practical prescription, either a new set of behaviors (for BT) or a new set of beliefs (for RET), that will help the clients more effectively cope with their problems.

In the case of the behavior therapist, the prescription will typically involve a set of activities that the patient is to take home and practice. The therapist is comparable to a physical therapist offering simple, practical exercises to follow.

In the case of the cognitive therapist, there will probably be more discussion and interpersonal interaction with the client, challenging the client think through the problem and arrive at new solutions on their own that should make sense to them. Rather than just authoritatively pronouncing the treatment or telling the patient what they must do, the therapist asks pointed questions aimed to reveal why the client believes the situation to be as dire as it appears. The therapist then looks for flaws in the patient's logic -- irrational or overly critical ideas that keep the patient in a state of anxiety. The client and therapist then work through the problem by talking about it and arriving at a new way of thinking that makes more sense (Ellis, 1962).

Since RET is a directive form of therapy, Ellis conceptualized the role of an effective therapist as "an authoritative (but not authoritarian!) and encouraging teacher who strives to teach his or her clients how to be their own therapists once the therapy sessions have ended" (Ellis 1979).


Types of interventions used by behavior therapists include counter-conditioning, desensitization and assertiveness training. Wolpe (1969) applied behaviorist ideas in clinical practice to help patients overcome fears and inhibitions. He developed a method called systematic desensitization (Wolpe, 1969, pp. 100-122). Rather than directly confronting situations that cause debilitating fear or anxiety, the client was first instructed to practice bodily relaxation techniques. Then, once they were relaxed, the fear-producing stimulus would be introduced, at first in nonthreatening or imaginary scenarios followed by gradually more vivid ways, while the patient maintains his or her calm composure.

A key principle in this type of BT, as outlined by Wolpe (1973), is reciprocal inhibition. According to Wolpe (1973, p. 17), "if a response inhibiting anxiety can be made to occur in the presence of anxiety-evoking stimuli, it will weaken the bond between these stimuli and anxiety." Behavior therapists thus use physical relaxation as a means of reversing anxiety responses to stimuli associated with threats. Relaxation is seen as incompatible with anxiety.

Behavior therapy, as it is rooted in behaviorist psychology, assumes a deterministic model of human behavior. Humans acquire patterns and habits of behavior as a response to rewards and punishments that are largely imposed on us, outside our control. RET assumes that people can exercise more personal agency in constructing their own reality. Ellis advised patients to "realize that they create, to a large degree, their own psychological disturbances and that while environmental conditions can contribute to their problems they are in general of secondary consideration in the change process" (Ellis & Dryden 1987, 25). In the course of therapy, the client is asked to identify their irrational beliefs and to replace them with rational alternatives. In this way, the client's outlook can change to a more positive, emotionally balanced mode of being in the world, even while their objective circumstances may remain unchanged.

Cognitive therapy is antithetical to radical behaviorism, since behaviorism historically has set aside mentalistic models as outside empirical science and evoking unobservable variables. Cognitive psychologists may see simple stimulus-response sequences as inadequate to accounting for human behavior. They incorporate in their model the internal thought processes that underlie patterns of action.

Cognitive therapies can incorporate human language and meaning systems to understand negative behavior patterns as a result of self-defeating ideation. The patient's anxiety and maladaptive responses may issue from negative self-narratives, or refusal to think through that which they find disturbing in their daily lives.


The proof of the effectiveness of BT is to be judged by delivering observable and measurable changes in the troubling behavior. Behavior therapy in its pure form does not appeal to a theoretical model of the mind to explain the behavior. Behavior can be modified by external influences, changing the conditions that elicit a behavior. It draws on the operant conditioning models of B.F. Skinner. In accordance with the materialistic and behavioristic paradigm, anxiety can also be objectively measured in terms of physiological responses mediated by the central nervous system in response to threatening stimuli.

In RET, "rational" means "that which helps people achieve their goals and purposes," whatever the individuals set their personal goals, and "irrational" means "that which prevents people from achieving their goals and purposes" (Dryden, 1984, 238). Ellis characterizes rational beliefs as personal preferences (not absolutes). They derive from effective means to attain personal wishes and goals. Irrational beliefs, in contrast, are absolute or dogmatic in nature, entailing imperatives such as "should" or "must," and interfere with the attainment of personal goals (Ellis & Dryden 1987, 6).

The kinds of irrational beliefs Ellis' therapy was designed to address included living up to other's expectations (the belief that one must be approved by others), or socially imposed guilt over sexual desires (1983). Beck (1967) treated depression by challenging the "cognitive triad" of negative views of self, the world, and the future. Patients were talked through these self-defeating beliefs and shown how they were distorted. In this way, the therapist attempted to change the cognitive schema that maintained a negative view of self and a depressive emotional state.

Cognitive therapies express a faith in rationality. There is the assumption that a reasonable and realistic view of oneself and the world will promote happiness and feelings of well being, while negative feelings must be rooted in distortions and failures of logic.

In order to compare and contrast behavioral and cognitive forms of therapy, let's consider how a therapist might treat a patient with Obsessive-Compulsive Disorder (OCD). OCD is "an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions)" (Stein, Denys, & Gloster 2009). OCD is a long-term chronic disorder that fluctuates in severity over time. The obsessions (the cognitive aspect of the disorder) consist of unwanted, intrusive thoughts, which cause great anxiety. An OCD sufferer may experience intense anxiety over fears of contamination, often subjectively triggered by an environmental cue. For example, an object such as a smoke alarm may come to be associated with an anxiety attack to an OCD sufferer who has learned that these devices contain trace amounts of radioactive elements. The compulsions (the behavioral aspect of the disorder) consist of ritualized, repetitive behaviors the afflicted person devises in order to quell the anxiety. When the person believes he has come in contact with a radiation-contaminated smoke alarm, to continue the example, he may frantically wash his hands for hours in order to cleanse himself of the imagined radioactive isotopes.

OCD may be treated with antidepressants called selective serotonin reuptake inhibitors (SSRI), which include: Citalopram (Celexa), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft) (Vorvick, Merell, & Zieve, 2010). These drugs have been shown to reduce anxiety, so that the patient is better able to put the obsessive thought out of his mind and resist the urge to indulge in compulsive behaviors. Cognitive behavioral therapy (CBT) has also been shown to be an… [END OF PREVIEW]

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