Putting the “B” Back into Cognitive-Behavioral Therapy

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While many clinicians claim to employ cognitive-behavioral principles in their strategies, often their interventions go light on the behavioral aspects of CBT and wind up looking far more like Cognitive Therapy (CT) than CBT.

Not too long ago, a middle aged man I’ll call David sought my professional counsel in desperation. (Elements of this story have been distorted so as to preserve anonymity.) He’d already been to one counselor and even participated in a structured treatment program in an effort to overcome a gambling addiction, without much success. While he was hopeful that I might be able to help, he was also more than a bit apprehensive. He knew that I worked primarily within a cognitive-behavioral therapy (CBT) framework. But his prior treatments also purportedly adopted the CBT framework and as he saw it, they “didn’t work.” David’s motivation to change appeared both genuine and high and wasn’t a factor in his past treatment failures. He clearly wanted help but couldn’t help but doubt whether what I might have to offer him (or, for that matter, what anyone might offer him in the way of intervention) would be effective.

Fortunately David brought with him all of his CBT “workbook” material. His dutifully completed assignments confirmed how invested he had been in his treatment and how well he understood all the concepts. In carefully scrutinizing his lesson plans and worksheets, I discovered something I’ve actually encountered numerous times before: the treatments he’d been exposed to were good as far as they went, but they were not what I’d call genuine CBT programs. Why? Because the most critical part of the CBT paradigm was almost completely left out or ignored: the “B” part, or behavioral component.

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Cognitive-Behavioral Therapy (CBT) is a relatively recent mode of therapeutic intervention that has demonstrated efficacy in the treatment of a wide range of psychological conditions. Those familiar with my books (In Sheep’s Clothing and Character Disturbance) and online articles already know that in my work with impaired and disordered characters, I most often operate within the CBT paradigm. That’s because my experience has taught me that this particular treatment modality is superior to most others when it comes to helping an individual with a character disturbance change for the better (for more on this see: “Dealing With Character Disturbance is All a Matter of Perspective”). I’ve written several articles that reference this mode of intervention (see, for example: “Cost-Benefit Analysis in CBT: An Exercise in Behavioral Economics”). I think there are some things about working within the CBT paradigm that can’t be stressed often enough, especially how important it is for the principles of sound behavior therapy to be incorporated into a CBT treatment plan.

Most clinicians I know harbor more than a few negative feelings toward behavior therapy per se. They tend to see it as both a “dry” and superficial paradigm. They’ll commonly say things like: “It might get someone to change their outward behavior but it ignores the underlying problem so it can’t help a person really change in the long run.” Many find the mechanics of behavior therapy distasteful as well (i.e. fashioning reinforcement schedules, doing cost-benefit analyses, detecting and altering behavioral cues, modifying cue saliency, monitoring target behavior, devising reinforcements for alternative behaviors, etc.). While the empirical research consistently affirms the efficacy and sometimes superiority of behavior therapy, they’ll insist: “Human beings are not lab rats! We can’t just reinforce them for doing one thing or punish them for doing something else and expect them to be genuinely healthier persons as a result.”

Because the attitudes I’ve mentioned are so commonplace, what I’ve learned over the years is that while many programs and clinicians will claim to employ CBT principles in their intervention strategies, the interventions actually look far more like Cognitive Therapy (CT) than CBT when closely examined. Such was the case with the program “David” brought to my attention. It was also true of the individual counseling he’d received. Almost all the focus was on his predisposing cognitions and feelings and virtually no attention was given to his various problematic behaviors and the contingencies influencing the occurrence of those behaviors.

Many of you are already familiar with the basic principle of CBT: the way we think heavily influences how we act. So, if we change the way we look at things, we’re more likely to change the way we behave. (For more on Cognitive Therapy and the evolution of CBT, see An Introduction to Cognitive Therapy & Cognitive Behavioural Approaches). But here’s another reality many forget: the kinds of behaviors we engage in and the feedback we get from our environment regarding those behaviors heavily influence the way we think about things. In other words, by doing things differently and by seeing how our lives change as a result, we necessarily change our attitudes as well as our beliefs. Anyone who’s ever overcome a simple phobia knows how true this is. A person afraid of spiders, for example, might entertain all sorts of thoughts like “they’re poisonous and can kill me” to “they’re ugly and just being near them will freak me out!” And naturally, such thoughts will predispose them to go out of their way to avoid the creatures. But once an arachnophobe dares to come into contact with a spider or two on a couple of occasions (often, this has to be done gradually, or through what is called “successive approximations”) and finds out that the world has not come to an end, their thoughts and even feelings about these little monsters inevitably change.

In the end, David got some training in covert self-monitoring (a fancy term for being more mindful of certain behaviors and the situations that generally immediately precede those behaviors) and covert self-reinforcement (a term for giving oneself an internal pat on the back) for initiating alternative behaviors, and with a lot of hard work eventually became a non-practicing gambling addict. For him, the first step was to take greater notice of the “chain” of subtle behaviors on the “slippery slope” that almost always led to his gambling and to replace those behaviors (and reinforce himself for so doing) with behaviors that made it less likely he would succumb to the temptation. Every time he took such a step, his outlook on things — even his outlook on life — changed. Armed with a new way of seeing and feeling about things, he was also less inclined to engage in the behaviors that tempted him to gamble. It was truly a two way street of new empowerment. It was also a testament to the real power of CBT.

We don’t really have much choice over our feelings, sensations, or even our strong urges. But we can exercise control over our thoughts and our behavior. While some might suggest that in so doing a person is only superficially changed, I can assure you David is not the same person who not too long ago lived in panic with a life out of control and came to see me in such desperation. He may always retain addictive tendencies and may still have other issues to work on, but thanks to his own determination and his faithful use of the tools he learned in CBT, he’s a very different guy.

All clinical material on this site is peer reviewed by one or more clinical psychologists or other qualified mental health professionals. This specific article was originally published by on and was last reviewed or updated by Dr Greg Mulhauser, Managing Editor on .

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