BEHAVIOR THERAPY 28, 341-345, 1997

The Relation Between Cognitive and Behavioral Therapies Commentary on "Extending the Goals of Behavior Therapy

and of Cognitive Behavior Therapy"

DAVID REITMAN

Louisiana State University

Ellis (1997) describes how Rational Emotive Behavior Therapy (REBT) can be dis- tinguished from Behavior Therapy (BT) and, perhaps more significantly, "adds" to BT. Among the issues raised by Ellis is the suggestion that traditional BT may lead only to temporary or superficial behavior changes, and that the goals of BT should be extended to include more comprehensive and enduring "personality change" In this commentary, I discuss the underlying medical model adopted by cognitive thera- pists, the empirical data that bear on the issue of "adding" to BT, and an alternative framework to evaluate clinical practice. It is suggested that there are more similari- ties among therapists, and their therapies, than differences. Thus, as Charles Ferster (1972) suggested 25 years ago, more effort should be devoted to studying what suc- cessful therapists do, and less to arguing the merits of therapists' theoretically informed explanations for success.

Rational Emotive Behavior Therapy (REBT) is distinguished by Ellis (1997) from Behavior Therapy (BT) because it goes beyond "symptom alle- viation" to attempt more comprehensive cognitive or philosophic restruc- turing and personality change. Through the use of several "cognitive, emo- tive, and behavioral methods," REBT aims for enduring changes in clients' thinking that render them both less disturbed and less disturbable. Ellis describes some of the ways that REBT can be distinguished from BT, and perhaps more significantly, "adds" to BT. The distinctions drawn by Ellis be- tween BT and cognitive behavior therapy (CBT), as well as their implica- tions, form the basis of this commentary.

Among the issues raised by Ellis (1997) is the suggestion that traditional BT may lead to superficial or temporary behavior changes and that the goals of BT should be extended to include more comprehensive "personality change" Closer inspection reveals that these concerns derive from an accep- tance of the medical model by cognitive therapists (Krasner, 1992). When

Correspondence concerning this article should be addressed to David Reitman, Department of Psychology, Louisiana State University, 236 Audubon Hall, Baton Rouge, LA 70803; e-mail: dreitma@unixl.sncc.lsu.edu.

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applied to human behavior, the medical model assumes that the causes of maladaptive behavior arise from "inner" sources such as irrational beliefs, distorted cognitions, or biologically based disease entities. By contrast, behavioral approaches adhere to an "outer model" of psychopathology. Con- temporary cognitive therapies, including REBT, share with psychoanalysis an acceptance of the medical model, and this "inner model" of psychopathol- ogy forms the basis of their more fundamental agreement.

Given the acceptance of the inner model, it is not surprising that Ellis (1997) argues that "long-term follow-up studies [of BT] are not done, and little effort is made to see whether people who are helped with their original symptoms (e.g., posttraumatic stress disorder) later develop other symptoms (e.g., depression)" (p. 333). Similar claims were made by psychoanalysts regarding the supposed inevitability of symptom substitution following suc- cessful behavior modification efforts (Ullman & Krasner, 1965).

One may question whether behavior therapists should adopt the goal to effect profound philosophical change. At what point along the behavioral change continuum, for example, would one declare that "profound per- sonality changes" have occurred? and how would this differ from observed and documented behavior changes over an extended period after therapy? One could recast the pursuit of "personality change" as a problem of mainte- nance and generalization of change; a topic familiar to many behavior ther- apists and accompanied by a substantial research base (see Stokes & Baer, 1977). Long-term changes in a client's behavioral repertoire that lead to less disturbance in the future (i.e., maintenance and generalization of change) seem as desirable and possible from within the less self-consciously "cogni- tive" therapies (e.g., desensitization) as with the therapies that Ellis (1997) describes as CBT.

Radical behavioral (contextual) therapies, such as Functional Analytic Psychotherapy and Acceptance and Commitment Therapy, regard thinking and feeling as important but noncausal. Applications of the operant model to nonverbal behaviors, and alterations of behavior produced through non- verbal methods, have been highly successful in many settings, and especially with children and developmentally disabled populations (Miltenberger, 1997). Yet, for the most part, the initial promise of viewing adult human verbal behavior and the client-therapist relationship in contextualized, operant terms, has not been realized. In this vein, consider Salzinger's (1992) comments on an intervention for depressed persons with Alzheimer's disease.

Under the rubric of "cognitive" the therapists said they "examined thoughts and identified distortions," helping the patients to produce more adaptive thoughts appro- priate to the situations. When they examined thoughts and identified distortions (as they said), the ther- apist clearly must have presented negative reinforcers (disagreeing verbal behavior) that could only be escaped

COMMENTARY ON "EXTENDING THE GOALS" 343

from by the patients emitting "appropriate verbal responses" ostensibly free of distortions. The proce- dures used by the therapists were not at fault; their description however, was "cognitive" and made them sound as if one could simply point out distortions and thus modify the verbal behavior of patients. (p. 6)

The issue raised here by Salzinger is vital to an understanding of how ther- apists (not therapies!) produce behavior change and to our growth as a science interested in those changes. Careful description of therapist behaviors and their relation to changes in client behavior are extremely valuable. For example, Truax's (1966) discrimination-based analysis of client-centered therapy led to a greater appreciation of the role of therapist approval in the psychotherapy process literature. Yet excessive appeals to unseen entities within the individual obscure the analysis of therapist actions that may result in the very cognitive changes in clients that CBT adherents seek to induce. As Haaga and Davidson (1986) caution, "rather than assuming that all musts or reality distortions are to be eradicated, cognitive therapists would do well to consider the potential utility of such thoughts" (p. 237).

Assuming that therapists can be distinguished only by observing their actions with respect to their clients, what have the unique procedures asso- ciated with REBT (e.g., identification and disputation of irrational beliefs) contributed or added to behavior therapy's effectiveness as a behavior change strategy? In terms of empirical data showing the superiority of REBT over other forms of BT (e.g., systematic desensitization), REBT has contributed very little (Engels, Garnefski, Diekstra, 1993; Gossette & O'Brien, 1992, 1993; Lyons & Woods, 1991). Parenthetically, similar criticisms have been lodged at cognitive therapies in general, and Beck's cognitive therapy in par- ticular (e.g., Beidel & Turner, 1986; Miller & Berman, 1983; Wolpe, 1993). Nevertheless, REBT does appear to be more efficacious than no treatment (Engels et al., 1993; Lyons & Woods). Unfortunately, the effectiveness of REBT has been established too frequently from self-reports indicating reduc- tions in the number of irrational beliefs held by patients rather than by demon- strating change in clinically relevant target behaviors (e.g., Gossette & O'Brien, 1993). Other evaluations appear to support Ellis' (1997) contention that cognitive therapies can produce long-term changes of the more profound long-lasting type sought by REBT practitioners, even though the best known results of this sort have been documented with Beck's cognitive therapy for depression (see Beck, 1991). Given the scant evidence for the superiority of "cognitive change" procedures, how should behavior therapists approach the future?

Instead of claiming that cognitive therapies and behavioral therapies (or perhaps even psychotherapy practices in general) are equally efficacious but qualitatively different approaches to behavior change, it may be better to say that the most effective therapies are fundamentally the same (e.g., Frank,

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1973). Ferster's (1972) insights on the relation between behavior therapy and psychoanalytic practice may prove instructive: "Insight therapy may become behavioral even if it is not behavior therapy" (p. 2); "If the techniques of insight therapy modify behavior in useful ways, then they can uncover new phenomena for the behavior therapist" (p. 1); and "By paying attention to the behavioral observations rather than the theory, a behavioral analysis may dis- cover the kinds of conduct that are useful targets for behavior modification procedures" (p. 2).

With "cognitive" substituted for "insight," Ferster's (1972) comments may still have utility for behavior therapists. Perhaps, as Ellis (1997) suggests, most therapists do sense that their clients have "unrealistic, illogical beliefs, and philosophies" and perhaps therapists do "try to talk them out of dysfunc- tional feelings and actions" If future data support Ellis' argument that REBT and CBT "adds" significantly (e.g., lead to greater efficacy) to BT procedur- ally, then all behavior therapists should be interested in those interventions. As Charles Ferster suggested 25 years ago, more effort should be devoted to studying what successful therapists do and less to arguing the merits of thera- pists' theoretically informed explanations for success. A more careful descrip- tive and experimental analysis of our therapeutic activities will do more to advance our science than theory-based polemics.

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RECEIVED: May 16, 1997 ACCEPTED: June 16, 1997