COGNITIVE BEHAVIOR THERAPY Research and Application

COGNITIVE BEHAVIOR THERAPY Research and Application

Edited by John P. Foreyt Baylor College of Medicine Houston, Texas

and Diana P. Rathjen Rice University Houston, Texas

PLENUM PRESS • NEW YORK AND LONDON

Library of Congress Cataloging in Publication Data

Main entry under title:

Cognitive behavior therapy.

Includes bibliographies and index. 1. Cognitive therapy. I. Foreyt, John Paul. II. Rathjen, Diana P.

RC489.C63C63 616.8'914 ISBN-13: 978-1-4684-2498-0 e-ISBN-13: 978-1-4684-2496-6 DOl: 10.1007/978-1-4684-2496-6

© 1978 Plenum Press, New York A Division of Plenum Publishing Corporation 227 West 17th Street, New York, N.Y. 10011

All rights reserved

78-15948

No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

Contributors

Aaron T. Beck, M.D., Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania

John G. Bruhn, Ph.D., Community Affairs and Special Programs, University of Texas, Medical Branch, Galveston, Texas

David D. Burns, M.D., Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania

Roy Cameron, Ph.D., Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Patrick H. Doyle, Ph.D., Department of Psychology, University of Houston, Clear Lake City, Texas

John P. Foreyt, Ph.D., Departments of Medicine and Psychiatry, Baylor College of Medicine, Houston, Texas

w. Doyle Gentry, Ph.D., Department of Psychiatry, Duke University Medical Center, Durham, North Carolina

Alice Hiniker, Ph.D., Texas Research Institute of Mental Sciences, Houston, Texas

Raymond W. Novaco, Ph.D., Program of Social Ecology, University of California, Irvine, California

v

vi CONTRIBUTORS

Diana P. Rathjen, Ph.D., Department of Psychology, Rice Univer­sity, Houston, Texas

Eric D. Rathjen, Ph.D., Mental Health-Mental Retardation Author­ity, Harris County, Houston, Texas

Jeffrey C. Steger, Ph.D., Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington

Dennis C. Turk, Ph.D., Department of Psychology, Yale University, New Haven, Connecticut

G. Terence Wilson, Ph.D., Graduate School of Applied and Profes­sional Psychology, Rutgers University, New Brunswick, New Jersey

Foreword

The recent development of cognitive theories and therapies within the ranks of behavior therapy has to be classified as one of the more intriguing developments in contemporary clinical psychology. After all, "behaviorists" have long been stereotyped as cold, hard-headed environmentalists who have been anything but subtle in their at­tacks on mentalism. To those who have accepted such a stereotype, a "cognitive behavior therapist" might sound like a self-contradic­tory creature, one steeped in two separate and incompatible psy­chological traditions. How can one be both "cognitive" and "be­havioral"? This is only one of the issues addressed in the present volume, which represents a valuable contribution toward both the­oretical and empirical refinements in the area. Here one can read how the behavioristic emphases on assessment and experi­mentation can be fruitfully integrated with therapeutic procedures designed to alter patterns of human distress. Many of those procedures involve specific focus on a client's thoughts and fantasies.

This book represents a strong and timely overview of an excit­ing new area, and its contributors include some of the most ener­getic researchers in the field. A theme of cautious optimism is blended with a commitment to empirical scrutiny, and there is an admirable recognition of the important difference between inferred therapeutic process and operationally specified therapeutic proce­dure. It is therefore a volume that should appeal to both researcher

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viii FOREWORD

and practitioner, and it is a valuable resource for exploring some of the newer applications of cognitive behavioral techniques.

There are those within behavioral and nonbehavioral camps who will be dismayed by the appearance of a volume such as the present one. They are, however (1 think), in the minority relative to the number of professionals who will be intrigued by these strange bedfellows and eager to explore their theoretical and pragmatic via­bility. A recent survey of American clinical psychologists suggests that cognitive behavioral approaches are now more popular than client-centered therapy, and that the recent increase in ideological eclecticism may partially reflect the increasing permeability be­tween former polarities. The behavior therapist is now relying on assessment and treatment strategies that acknowledge the impor­tance of cognitive processes in human adaptation. Likewise, the nonbehavioral counselor seems to be more frequently borrowing from traditionally behavioral methods. In integrating their relative skills and special interests, it is my hope that we may soon be able to abandon the unfortunate polarities and isolationism that have dominated clinical psychology and psychiatry.

The present volume is, I think, a valuable step toward demon­strating the compatability and rich therapeutic promise of combin­ing intrapersonal, environmental, and scientific concerns. It does not promise miracles and is, in fact, commendable in its critical self-scrutiny. With modeling such as that offered in this book, we may hope to see continuing refinements of our understanding as well as revisions of our treatment strategies. Cognitive Behavior Therapy: Research and Application represents a welcome addition to the literature.

MICHAEL J. MAHONEY

Pennsylvania State University

Preface

Commenting on the first 50 years of behaviorism, Skinner (1964L in the early 1960s, noted:

No entity or process which has any useful explanatory force is to be rejected on the ground that it is subjective or mental. The data which have made it important must, however, be studied and formulated in effective ways. The assignment is well within the scope of an experi­mental analysis of behavior, which thus offers a promising alternative to a commitment to pure description on the one hand and an appeal to mentalistic theories on the other. (Skinner, B. F. Behaviorism at fifty. In T.W. Wann (Ed.), Behaviorism and phenomenology: Contrasting bases for modern psychology. Chicago: The University of Chicago Press, 1964, p. 96.)

In the intervening years, psychologists applying behavioral principles to clinical problems have attempted to provide the data Skinner suggests. In particular, the work of Albert Ellis, Aaron Beck, and Albert Bandura has steadily kept alive a cognitive frame­work introduced by the early social psychologists such as Julian Rotter and George Kelly.

The renewed interest in a merger or at least dialogue between the proponents of a cognitive and a behavioral perspective in un­derstanding human behavior is an exciting recent development in the field of psychology. In addition to the intellectual stimulation provided by such a rapprochement, practical implications for clini­cal treatment may also be forthcoming.

This book is an effort to explore current answers to the ques­ix

x PREFACE

tion, What is the role of cognitive factors in clinical treatment? Each of the authors presents a unique perspective revealing no overall consensus but rather a diverse collection of thought-provoking pos­sibilities.

The idea for this volume originated at the Sixth Annual Sym­posium of the Houston Behavior Therapy Association (HBTA), Houston, Texas. We are deeply indebted to each of the authors for their outstanding contributions. We are also grateful to the co-spon­sors of the symposium: University of Houston, Rice University, Baylor College of Medicine, and Spring Branch Academy, Houston, Texas. Each year HBT A presents a topic of significance to behavior therapists and others concerned with behavioral issues. Our sym­posium is successful only because of the hard work of many people, including HBTA members Drs. Pat Doyle, Richard Jones, Ed Keuer, Paul Mader, Sander Martin, Ben Williams, and in particular, Martha Frede and Larry Brandt who co-chaired the conference. Thanks also to Mr. Bill Kortas for his hard work and Ms. Susi LeBaron for her never-ending task of typing the manuscript. To all of them, our deepest gratitude.

Houston Texas

JOHN P. FOREYT

DIANA P. RATHJEN

Contents

INTRODUCTION .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. COGNITIVE BEHAVIOR THERAPY: PARADIGM SHIFT OR PASSING

PHASE? ................................................ 7

G. Terence Wilson

Behavior Therapy in the 1970s: Current Conceptual Models 8 The Cognitive Therapies: A Paradigm Shift? . . . . . . . . . . . . . . 16 Cognitive (Behavior) Therapy: A Passing Phase? . . . . . . . . .. 21 The Clinical Efficacy of the Cognitive Therapies. . . . . . . . . .. 26 A Terminological Note. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

2. A COGNITIVE ANALYSIS OF SOCIAL PERFORMANCE: IMPLICA­

TIONS FOR ASSESSMENT AND TREATMENT. . .. .. .. . . .. .. .. .. . 33

Diana P. Rathjen, Eric D. Rathjen, and Alice Hiniker

A Cognitive and Behavioral Definition of Social Competence 33 Cognitive Techniques for Cognitive-Affective Change ..... 57 Cognitive Techniques for Behavior Change . . . . . . . . . . . . . . . 67 Summary and Conclusions .... . . . . . . . . . . . . . . . . . . . . . . . . .. 73 References ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

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xii CONTENTS

3. COGNITIVE BEHAVIORAL STRATEGIES IN THE TREATMENT OF

SEXUAL PROBLEMS ...................................... 77

Jeffrey C. Steger

Definition of Sexual Difficulties . . . . . . . . . . . . . . . . . . . . . . . . .. 79 Overview of the Strategies for the Treatment of Sexual Dys-

function ............................................. 83 Description and Utility of Specific Cognitive Behavioral

Techniques .......................................... 90 Conclusion ............................................. 102 References ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 104

4. COGNITIVE BEHAVIOR MODIFICATION OF MOOD DISORDERS .. 109

David D. Burns and Aaron T. Beck

Characteristics of Cognitive Behavior Therapy ............ 114 Cognitive Distortions in Depressed Patients .............. 116 Cognitive Distortions in Anxious Patients . . . . . . . . . . . . . . .. 126 Comparative Efficacy of Cognitive Behavior Modification

versus Antidepressant Drug Therapy in the Treatment of Depressed and Anxious Patients . . . . . . . . . . . . . . . . . . . . . .. 131

References ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 134

5. ANGER AND COPING WITH STRESS: COGNITIVE BEHAVIORAL

INTERVENTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 135

Raymond W. Novaco

Human Stress ......................................... , 136 Anger and Its Determinants ..... . . . . . . . . . . . . . . . . . . . . . . .. 139 Cognitive Mediators of Anger Arousal ................... 142 Basis for a Cognitive Therapy for Anger .................. 145 The Stress-Inoculation Model ............................ 147 Application Practice .................................... 151 Experimental Evaluation ................................ 151 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 157

CONTENTS xiii

Appendix: Therapeutic Interventions for Anger Problems.. 162 Assessment of Anger Problems . . . . . . . . . . . . . . . . . . . . . . . . .. 162 Treatment Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 165 References ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173

6. COGNITIVE TREATMENT OF SOMATIC DISORDERS ............ 175

W. Doyle Gentry

Literature Review ...................................... 176 Other Areas of Application. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181 Role of Cognitions in Biofeedback ....................... 183 The CAB versus the ABC Model . . . . . . . . . . . . . . . . . . . . . . . .. 184 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185

7. COUNTERSENSITIZATION: AN AVERSIVE CONDITIONING MODEL

FOR SELF-CONTROL OF EXCESSIVE PERFORMANCE STANDARDS. 189

Patrick H. Doyle and John G. Bruhn

Description of Covert Sensitization ...................... 189 A Conditioning Conceptualization of Excessive Self-

Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 190 Covert Sensitization of Excessive Self-Standards. . . . . . . . . .. 190 Countersensitization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 191 A Modified Countersensitization Approach. . . . . . . . . . . . . .. 192 Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 193 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 196 References ............................................ , 197

8. COGNITIVE BEHAVIORAL TECHNIQUES IN THE MANAGEMENT

OF PAIN ................................................ 199

Dennis C. Turk

Conceptualizations of Pain ..... . . . . . . . . . . . . . . . . . . . . . . . .. 200 Cognitive Behavioral Treatments for Anxiety-Based Dys-

functions-Coping-Skills Approaches .................. 203

xiv CONTENTS

Cognitive and Behavioral Coping Strategies .............. 210 Multidimensional, Cognitive Behavioral Approaches for

Pain Management-Clinical ........................... 212 Multidimensional Coping Skills for Pain Management-

Laboratory-Analogue Studies .......................... 217 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 227 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 227

9. THE CLINICAL IMPLEMENTATION OF BEHAVIOR CHANGE

TECHNIQUES: A COGNITIVEL Y ORIENTED CONCEPTUALIZATION

OF THERAPEUTIC "COMPLIANCE" AND "RESISTANCE"

Roy Cameron

233

The Referral Stage ...................................... 236 Establishing a Therapeutic Alliance ...................... 240 Problem Formulation ................................... 242 Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244 Concluding Statement .................................. 248 References ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 248

AUTHOR INDEX 251

SUBJECT INDEX 257