Compare and Contrast Between Albert Ellis\' Cognitive Therapy and Behavior Therapy

Tom Shulich ("Coltish Hum")

A Critical Comparison of Behavior Therapy and Rational-Emotive Therapy

In this paper, I consider the benefits and drawbacks of behavior therapy and the cognitive therapy. These are talking therapies that now have over a half-century of application in clinical settings and are still used today in conjunction with, or as an alternative to, drug treatments of psychological disorders. I conclude that these therapies are still useful, though each has its limitations.

Behavior therapy (BT) and rational-emotive therapy (RET) were developed in the mid 20th century as alternative psychotherapies to Freudian psychoanalysis. A key foundational text for BT is Joseph Wolpe's (1958) Psychotherapy by Reciprocal Inhibition. Rational-emotive therapy (originally called simply "rational therapy") was founded in 1955 by Albert Ellis (Ellis & Dryden 1987, p. 1). Ellis' RET incorporates aspects of learning theory, which is central to BT, but goes beyond BT to utilize the central concept of "cognition," which includes subjective beliefs, narratives, language, and the attendant feelings these internal thoughts invoke. Rational-emotive therapy is thus seen as an early form of "cognitive-behavioral therapy" (National Association of Cognitive-Behavioral Therapists [NABCT] 2010).

Wolpe's (1958) Psychotherapy by Reciprocal Inhibition grew out of findings from his laboratory experiments on cats. Wolpe was able to demonstrate that he could inhibit the animals' fear responses by feeding them while gradually introducing and intensifying stimuli that would previously have frightened them. Wolpe extended this technique to humans, treating phobias and inhibitions through gradual desensitization by getting the patients to physically relax while gradually introducing increasingly intense exposure to things that produced anxiety, within the safe, controlled context of a therapy session.

Wolpe based his BT on the experimental psychology of behaviorists. Behaviorism was pioneered in the early 20th century by the Russian physiologist Ivan Petrovich Pavlov in his studies of the digestive system. Pavlov was interested in reflexive and involuntary reactions to anticipatory rewards. His experiments with dogs demonstrated the phenomenon of the "conditioned reflex."[footnoteRef:1] Pavlov demonstrated that an involuntary, instinctual behavior (such as salivating) could be activated by an artificial, environmental cue (such as the ringing a dinner bell). [1: In Russian, also translated as "conditional reflex."]

The idea of conditioning as a fundamental learning process was further developed in the United States by behaviorists, notably John B. Watson and B.F. Skinner, who argued that the investigation into overt, observable behavior constituted a more scientific basis for psychology than investigation into the subjective phenomena mental states or feelings.

Skinner's studies of lab rats went beyond Pavlovian classical conditioning (eliciting an involuntary reflex by paring the behavior with an environmental stimulus) by experimenting in operant conditioning (increasing/decreasing voluntary behaviors using reward/punishment). Skinner (1953) distinguished four types of operant conditioning:

1. Positive reinforcement occurs when a behavior increases in frequency as it is rewarded by a desirable stimulus. A child cleans her plate at dinner and her mother rewards her with desert.

2. Negative reinforcement occurs when a behavior increases in frequency as it is rewarded by the removal of a negative stimulus. A child cleans her plate so her mother will stop nagging at her.

3. Positive punishment occurs when a behavior decreases in response to an unpleasant stimulus. The child stops running around the house so her mother will not yell at her.

4. Negative punishment occurs when a behavior decreases as a result of a desired stimulus being removed. A child stops talking back so her toy will not be taken away.

The assumption of the behavioral psychologists is that most (or possibly all) behavioral maladjustments must have been acquired through learning. People come to suffer later in life from being rewarded early on for self-defeating behaviors, or punished for self-enhancing behaviors. Since our negative behaviors were acquired by conditioning in the first place, they could be undone and replaced by better behaviors by a deliberate course of beneficial conditioning.

Albert Ellis, a contemporary of Wolpe, developed a competing model of psychopathology, which incorporated some elements of BT, but also was more in line with the cognitive revolution. Over the course of his work in the 1940s as a clinical psychologist in New York City specializing in marital and sexual problems, Ellis grew dissatisfied with psychoanalysis as a means of problem solving (Ellis & Dryden 1987, p. 1). The psychoanalytic model Ellis was working from framed all relationship problems as the product of internal disturbances and conflicts within a person (Ellis 1962, p.3). Ellis based his alternative RET on ideas from Greek and Roman Stoic philosophers, such as Epictetus and Marcus Aurelius. Rather than internal psychodynamic conflicts, disturbances on this view were caused by irrational beliefs.

Mental constructs such as "beliefs" played no part in behaviorist psychology. The radical behaviorist view reduced all of human psychology to objectively observable behavior. Proponents of behaviorism saw their subject matter as more scientific than psychological theories that probed into unobservable constructs such as the unconscious mind or the superego. The positivist goal of reducing all of human experience to observable behavior came under challenge in the 1950s from advocates of cognitive science. Cognitive scientists, including linguists, psychologists, philosophers of mind, and computer programmers, proposed that internal mental activities that underlay action could be equally subject to scientific research, using introspection, as were overt behaviors.

Early investigations into cognition in experimental psychology predated the "cognitive revolution" of the 1950s, dating back to the works of William James and Wilhelm Wundt. These psychologists defined psychology as the science of mental life, and examined their own subjective experience using introspection.

Influential theoretical critiques of behaviorism came from linguists, such as Noam Chomsky (1959) and Lev Vygotsky (1962). These linguists argued that the syntax of a human language was so subtle and complex that reward and punishment for correct usage by adult speakers was insufficient to account for the acquisition of language. In light of its complex syntax, critics of behaviorism argued that language is impossible to analyze in behavioral terms alone. Instead, scientists should posit complex mental structures as the source of analysis.

This critique marked the beginnings of the cognitive revolution in psychology. Jean Piaget (1954) was a significant contributor to the field of cognitive psychology. Piaget studied the ways in which children build mental models of the world through observation and experimentation, not simple reward and punishment. Albert Ellis (1962) and Aaron Beck (1967) were early clinicians who applied cognitive ideas to promote mental health.

Models of Psychopathology

A key assumption of BT is that maladaptive behaviors are acquired through learning and they can be modified through additional learning; basically unlearning what is causing distress and relearning new habits (Wolpe, 1958). Following the arguments of the radical behaviorists, the maladaptive behavior is itself the disorder that the therapy addresses, not merely the symptom of some underlying mental problem. So effective BT should focus on changing the behavior itself, not taking a detour to explain in detail its underlying cause as a complex of developmental traumas. The basic premise of BT is: (a) emotional pathologies can be reduced to patterns of behavior, and (b) behaviors that have been learned can later be unlearned.

Cognitive therapists such as Ellis, in contrast, emphasize maladaptive thoughts as the underlying cause of psychopathology. Rather than focusing on changing overt behavior through reward and punishment, RET is designed to help the patient reorganize his or her self-defeating habits of thought that manifest externally as maladaptive behaviors.

Behavior therapy focuses narrowly on changing behavior, using reward and punishment to reshape the patient's overt behavior in a desired direction. Cognitive therapy conceives of overt behavior as the external expression of patterns of thought, feelings, and beliefs. In order to produce positive change, the therapist should help the client restructure their thought processes.

Ellis (1962) claimed that irrational beliefs are pervasive in human life and are easy to acquire without much thought or effort. For example, it is easier for many people to fall into a pattern of self-defeating behavior such as overeating than to deliberately craft a self-enhancing behavior such as following a sensible diet. Ellis also took a dim view of religion as a source of dogmatic, inflexible strictures that block people from achieving their desires and generate negative, inhibiting feelings such as guilt, self-condemnation and judgment of others. Ellis thought of religiosity as a central feature of human emotional and behavioral disturbance, since religious belief systems are absolutist, dogmatic, and include evaluative demands in the form of "ought," "must," and "have to."

In order to assess clients' psychological problems, Ellis developed an ABC framework, in which A stands for Activating event, B for a person's Belief about that event, and C. For the Consequences that will follow in light of that belief (Ellis 1962).

RET does not advance an elaborate theory of how people come to acquire psychological disturbances. Ellis saw people's tendency to arrive at irrational beliefs as part of our biological nature. Furthermore, simply knowing how a person developed an irrational belief does not suggest a therapeutic intervention, and RET is designed to provide practical solutions rather than elaborate explanations (Ellis & Dryden 1987, 22).

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).

Change

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.

Outcomes

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 effective type of therapy for this disorder. A common treatment is to reduce symptoms by using both medication and CBT, as both treatments used in conjunction are more effective than either treatment alone.