Cognition and the Cognitive Revolution

in Psychotherapy: Promises and Advances

䊲

E. Thomas Dowd
Kent State University

This article describes the history and conceptual changes wrought by the
gradual development from psychodynamic therapy to behavioral therapy
to cognitive–behavioral therapy. The practical impact of the cognitive rev-
olution on psychotherapy theory and practice is discussed. The empirical
status of behavioral therapy and cognitive–behavioral therapy is summa-
rized, and suggestions for future changes are made. © 2004 Wiley Peri-
odicals, Inc. J Clin Psychol 60: 415–428, 2004.

Keywords: cognition; cognitive therapy; cognitive revolution; history of

cognitive therapy

In this article, the nature of the cognitive revolution in psychotherapy will be described,
as will the resulting advances in the field of clinical psychology. While behavioral ther-
apy had provided an advance over psychoanalysis and associated mentalistic therapies,
the cognitive therapies continued to advance while somewhat ironically returning at least
in part to earlier formulations of the therapy process. In the end, behavioral therapy
proved too conceptually and technologically limited to provide a comprehensive expla-
nation of the psychotherapy process and human psychological change. The practical impli-
cations of this cognitive revolution also will be described.

Historical and Conceptual Changes in Behavioral and Cognitive Therapy

The recursive nature of human activity is a constant. Ancient proverbs express this well.
It has been said that one can never step into the same river twice nor does a bicycle wheel
ever touch the same road again as it turns. Ecclesiastices said, “There is nothing new
under the sun.” These folk proverbs point to a universal attribute of the human mind: its
ability to classify and reclassify sensory data into successive conceptual categories that

Correspondence concerning this article should be addressed to: E. Thomas Dowd, Department of Psychology,
118 Kent Hall, Kent State University, Kent, OH 44242; e-mail: edowd@kent.edu.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 60(4), 415–428 (2004) © 2004 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10253
416 Journal of Clinical Psychology, April 2004

are different and yet similar. Furthermore, humans often use metaphors to describe ideas
that are difficult to express directly. The evolution of the cognitive psychotherapies from
behavior therapy nicely illustrates these fundamental human attributes.

“In the Beginning There Was Freud . . .”

Although Freud’s ideas are currently out of favor in many circles, the continuing influ-
ence of his thinking hardly can be denied. Indeed, several generations of psychothera-
pists, in a kind of theoretical reaction formation, developed their ideas either in support or
extension of, or in opposition to, his groundbreaking theories. Philosophically, Freud was
a biological determinist, as well as a dualist (Ford & Urban, 1963), and saw human
activities as genetically constrained, developmentally channeled, and bound by opposing
forces. Such concepts as psychic energy, symptom substitution, sublimation, and drive
reduction were based on nineteenth-century science, a hydraulic model of personality,
with the machine as the guiding metaphor.
Two of Freud’s primary concepts, the theory of unconscious processes and motiva-
tion and the developmental antecedents of behavior (including childhood sexuality), were
truly revolutionary and caused him considerable trouble from the ecclesiastical authori-
ties of the time. The former, in particular, was a radical break from the ideas of the
Enlightenment, which assumed that individuals thought and acted rationally and con-
sciously and always knew why they acted as they did. Freud argued that much human
activity was not directed consciously, but the result of unconscious conflicts. The theory
of unconscious motivation was particularly influential and has entered the popular cul-
ture both as an explanation and as an excuse for bad behavior. The importance of devel-
opmental constraints on human behavior likewise was important because it implied that
childhood events had a powerful impact on subsequent attitudes and behaviors—and that
adult psychological change therefore was slow and uncertain. Fundamentally, Freud was
pessimistic about the possibility of rapid or extensive change in human psychological
functioning, and in that he was different from the behaviorists, but similar to the later
cognitive developmentalists (Dowd, 1997; Mahoney, 1991).
Another important Freudian concept was that of repression and resistance (Ford &
Urban, 1963). Unacceptable impulses were thought to be repressed and therefore resis-
tant to entering consciousness. For Freud, there was one central therapeutic goal—to
make the unconscious conscious (Prochaska, 1979) by overcoming that resistance. Two
important therapeutic interventions used to achieve that goal were free association and
interpretation, the former by allowing repressed material to enter consciousness and the
latter by helping the client to assign a different meaning to thoughts, feelings, and behav-
iors. Free association has been called client work because it is accomplished by client
activity, whereas interpretation has been called therapist work because the particular
form and content of the interpretation is the responsibility of the therapist (Prochaska,
1979). It is important to note that specific interpretation content was crucial in Freudian
psychoanalysis, and analytical arguments over correct interpretations of intrapsychic phe-
nomena often were fierce.

“Where Mind Was, There Shall Behavior Be . . .”

While European psychotherapy generally has been psychodynamically oriented, Ameri-

can psychotherapy has been influenced heavily by behavioral psychology. Beginning
with John Watson and Ivan Pavlov and continuing with E.L. Thorndike and B.F. Skinner,
 Cognitions and Psychotherapy 417

the locus of study shifted from introspection and the study of the mind to the develop-
ment and examination of the principles of behavior acquisition and change. In the pro-
cess, the mind was reduced to the status of an epiphenomenon (the black box), not because
it was unimportant or nonexistent, but because it could not be observed directly by another
individual (Skinner, 1953). Two explanatory principles underlie behaviorism: classical
conditioning, based on learning by association, and operant conditioning, based on learn-
ing by consequences (reinforcement). Behavioral psychotherapy developed interventions
from both. For example, systematic desensitization, in which clients are led through
progressively more anxiety-provoking scenes while relaxed, was based on classical con-
ditioning. Positive reinforcement was used in a variety of contexts and situations to con-
dition appropriate behavior, whereas extinction (lack of reinforcement) was used to
eliminate undesirable behavior. An important implication of behavior therapy was its
relatively ahistorical character. Because all behavior was learned, it also could be extin-
guished and new learning acquired. Behavioral psychologists, unlike Freud, were funda-
mentally optimistic about the possibility of significant change in human functioning—
probably because they viewed change as arising from different reinforcement contingencies
rather than from changes in core ordering processes. Thus, it was not necessary to inquire
about the past, only what the present reinforcement contingencies maintaining the prob-
lem behaviors were. The western philosophy of linear and unidirectional causality is a
guiding metaphor behind behaviorism.
Behavioral psychology and psychotherapy remained a strong force in American clin-
ical psychology for over 30 years; indeed, in some ways it remains influential to this day.
A variety of techniques were developed, including systematic desensitization, assertive-
ness training, and aversion therapies (Wolpe, 1990). More recently, additional methods,
such as flooding/implosive therapy, cognitive restructuring, and cognitive coping skills,
were incorporated into the behavioral therapy armamentarium (cf., Spiegler & Guevre-
mont, 1993). Many training programs in clinical psychology were and still are based on
a behavioral-therapy model.
Several factors, however, were responsible for the gradual diminishment of behavior
therapy’s primacy. First, while behavioral techniques were demonstrably effective, they
were often no more effective than alternative strategies. For example, the landmark out-
come study comparing behavior therapy with dynamic psychotherapy (Sloane, Staples,
Cristol, Yorkston, & Whipple, 1975) found no significant differences between the two
groups, either at the end of treatment or at one-year follow up. Precisely because behav-
ioral psychologists advocated and conducted empirical research, they were embarrassed
by research such as this, which showed no significant outcome differences among inter-
ventions. Second, while behavioral techniques were effective much of the time, they
were not effective all of the time—contrary to predictions derived from supposedly immu-
table laws of learning. In other words, the black box between the stimulus and the response
or between the response and the consequence seemed to be responsible for much more
variance than it should! Thus, the search began for an explanation of this unexpected and
unwanted variability. Third, there were conceptual analyses (cf. Breger & McGaugh,
1965; Murray & Jacobson, 1971) indicating that the process and nature of psychothera-
peutic change was considerably more complex and cognitively mediated than the basic
laws of learning would suggest.

“The Reciprocity of Conditioning . . .”

Beginning in the early 1960s, Albert Bandura developed his social-learning theory based
on the principle of reciprocal influence or counterconditioning (Bandura, 1969; Bandura
418 Journal of Clinical Psychology, April 2004

& Walters, 1963). Several of Bandura’s concepts and empirical findings showed the lim-
itations of a behavioral approach to therapy. Essentially, Bandura was able to demonstrate
through empirical research that not only do environmental contingencies influence human
behavior, but also humans in turn are able to influence themselves and others contin-
gently (i.e., their environment). Thus, influence is exercised in a reciprocal fashion. Sec-
ond, Bandura’s research showed that a perceived reinforcer was more reinforcing than an
actual reinforcer that was not perceived as such. Third, he was able to demonstrate that
individuals did not have to be reinforced directly for performing a behavior in order for
that behavior to increase in probability; it was sufficient for the individual to observe
another person (a model) being reinforced for performing that behavior. This demonstra-
tion of vicarious learning (or modeling effect) is one of Bandura’s most significant con-
tributions. These three findings indicated that what happened in the black box was of
crucial importance to operant conditioning itself and that learning was not an automatic
process, but one that was mediated by human cognition. What especially is significant is
that the research on modeling implied an opposite effect from what psychoanalysis might
predict as a result of catharsis. For example, modeling of aggressive behavior was shown
to increase that behavior, whereas cathartic expression of aggression might postulate a
decrease in aggression as the feelings were expressed. The machine model was beginning
to be replaced by an information-processing model. Behavioral principles such as reinforce-
ment, extinction, and (de)sensitization were now applied to private events such as thoughts
and images, in what came to be known as covert conditioning (Jacobs & Sachs, 1971) or
coverant control (Dowd, 2002a). While the problem focus changed from external to
internal behaviors, however, the fundamental conceptualization problem and the inter-
vention strategies applied remained behavioral.

“People Talk to Themselves . . .”

In the early 1970s, Donald Meichenbaum, originally trained in behavioral psychology,

made an important discovery. Drawing on the work of the Soviet psychologists A.R Luria
and L. Vygotsky, he found that children, when faced with a task, talk to themselves about
how to perform that task. He found that this private speech served as an important reg-
ulator of behavior. Developmentally, Meichenbaum argued, these self-verbalizations are
initially overt but, as the child grows older, they become increasingly covert to form the
internal dialogue. Meichenbaum used these ideas to develop a training program for impul-
sive children who, he said, showed deficits in the ability to regulate their behavior by
self-instructions. His training program consisted of several stages, beginning with an
adult model performing a task while talking out loud about how to perform the task, to
the child performing the task while talking out loud, to the child performing the task
while talking covertly. Subsequently, Meichenbaum developed a three-stage model of
stress-inoculation training involving an educational phase, a rehearsal phase of coping
techniques, and a practice phase of these new skills in the environment. These programs
formed the basis of his theory of cognitive–behavioral modification. According to this
theory, clients first become aware of their behavior and their internal dialogue about this
behavior. They then are trained in emitting incompatible behavior and internal dialogue
(i.e., talking to themselves differently) and finally trained to exhibit this new behavior in
the environment and to think differently about this new behavior (Meichenbaum, 1977).
There are two important aspects of Meichenbaum’s cognitive–behavioral modifica-
tion. First, it is essentially a behavioral theory. It is assumed that people behave first and
then think about and (re)conceptualize that behavior, a point made earlier by Hobbs
 Cognitions and Psychotherapy 419

(1962). The job of the therapist is to train the client to notice the behavior, to think about
and change the behavior, and then to reconstruct the internal dialogue about that behav-
ior. Thus, although the internal dialogue is an important regulator of behavior, it is behav-
ior itself that is to be changed first. Second, it assumes that different therapeutic systems
are not more or less true (as if there were an objective standard of Truth), but simply are
different explanatory constructs to help clients think about their problems differently—in
other words, to change the nature and content of their internal dialogue. As he stated,
. . . as a result of therapy a translation process takes place . . . The translation is from the
internal dialogue the client engaged in prior to therapy to a new language system that emerges
over the course of treatment. (Meichenbaum, 1977, p. 217).

The truth of a system of therapy, therefore, is not in its objective reality, but in its use-
fulness to the client. In this respect, Meichenbaum was a forerunner of what has now
come to be called Constructivism.

“It’s the Thought That Counts . . .”

The evolution of behavior therapy from a strict learning-theory perspective to a more

cognitively mediated perspective has just been described. However, the fundamental con-
ceptualization and many of the interventions remained behavioral. Parallel to the evolu-
tion of behavior therapy, there were developing systems of cognitive therapy that relied
on a cognitive conceptualization and cognitive interventions. The two most influential
figures in this movement are Albert Ellis and Aaron Beck. It is to a consideration of their
work that this article will now turn.
Albert Ellis is a clinical psychologist who originally was trained as a psychoanalyst.
Becoming impatient with the slowness of psychoanalysis and the inactivity of its practi-
tioners, he searched for a quicker way to help his clients change. He noticed that he often
realized the source of clients’ problems before they did and that these difficulties gener-
ally involved specific distorted thinking patterns that were common across clients. His
original Rational Therapy (RT) was developed to enable clients to recognize these dis-
tortions in thinking and to “vigorously dispute” them. Rational Therapy soon was expanded
to Rational–Emotive Therapy (Ellis, 1962) and more recently to Rational–Emotive–
Behavior Therapy [RE(B)T]. Because Ellis’s ideas have changed over time and because
he has been a very prolific writer, it is difficult to describe his ideas accurately at any
point in time. Despite the changes over the years, however, several commonalities might
be said to describe the Essential Ellis.
One of Ellis’s major contributions was his distinction between rational and irratio-
nal beliefs (Dryden & Ellis, 1986). While the definition of the two has fluctuated some-
what, rational beliefs are preferential and are useful in helping individuals get what they
want. Irrational beliefs, on the other hand, are more dogmatic and absolutist in nature and
may hinder or prevent individuals from getting what they want. There is a strong hedo-
nistic aspect to this theory and a tacit assumption that rational beliefs involve less nega-
tive affect than irrational beliefs. Drawing on Karen Horney’s work, Ellis argued that
individuals disturb themselves by their absolutist shoulds (e.g., “I should do that”) and
musts (e.g. “I must do this”), leading to a damning of themselves and strong negative
affect as they try to satisfy impossible demands.
Another of Ellis’s important contributions was the development of the A–B–C method
of cognitive and behavioral analysis and change. Following the Greek philosopher Epic-
titus, who said, “Men are not disturbed by things but by the view they take of things,”
420 Journal of Clinical Psychology, April 2004

Ellis argued that the belief (B) about the activating event (A) leads to the consequence
(C), rather than by a direct A–C connection. Therefore, one could change C by changing
B, even if A did not change. Although Ellis uses homework assignments extensively, his
theory is largely cognitive in nature, as it stresses a new view of things. Behavior change
is used in the service of cognitive change, and the ultimate goal is to bring about a
profound philosophical exchange rather than simple symptom relief.
RE(B)T is simultaneously optimistic and pessimistic about the human condition. It
is optimistic because it is assumed one can change one’s thinking even under very adverse
circumstances, and therefore improve one’s mental health. It is pessimistic because Ellis
believes that individuals have a strong biological tendency to think irrationally that they
can only partially overcome, and then only with effort. Recent writings in evolutionary
psychology applied to cognitive therapy have suggested that there may be some truth in
this view (Hofmann, Moscovitch, & Heinrichs, 2002; Leahy, 2002). At least as practiced
by Ellis and his close associates, RE(B)T involves a highly active and directive therapist
who identifies and helps the client vigorously dispute his/her irrational thoughts. Like
behavior therapy, it is very ahistorical because Ellis believes it is not necessary to inquire
into past events, thoughts, or feelings. All that is necessary is to identify and dispute
current irrational beliefs. Implicitly, it also is linear–causal in nature because the A–B–C
model appears unidirectional (i.e., A r B r C).
Aaron T. Beck is a psychiatrist who, like Ellis, originally was trained as a psycho-
analyst. Unlike Ellis, however, who is primarily a clinician, Beck has been primarily a
theoretician and researcher. Since he originally was interested in the study of depression
from a psychoanalytic perspective, he attempted to show that depression was related to
inward anger and hostility (Weishaar, 1993; Weishaar & Beck, 1986). Instead, he found
that the dreams of depressed individuals were characterized by themes of loss and sad-
ness. From those beginnings, Beck developed the Cognitive Model (Triad) of depression,
which is characterized by negative-content cognitions (automatic thoughts) of oneself,
the world, and the future. Furthermore, depression involves cognitive processing distor-
tions, such as arbitrary inference, selective abstraction, and overgeneralization. These
cognitive distortions are similar conceptually to Ellis’s irrational beliefs, but tend to be
more process oriented and idiosyncratic than Ellis’s more standard and content-oriented
list. Beck later expanded Cognitive Therapy to anxiety and phobias, where the cognitive
theme was considered a perception of danger (future oriented) rather than loss and sad-
ness (past oriented).
Beck’s Cognitive Therapy was, from the beginning, a time-limited therapy, usually
requiring about 16 sessions for the treatment of depression. While it gradually acquired a
rich armamentarium of techniques (Freeman, Pretzer, Fleming, & Simon, 1990), the
process of identifying and challenging automatic thoughts is central to Cognitive Ther-
apy and is the most commonly used technique. However, unlike Ellis’s common use of
direct disputation towards this end, Beck relies more on the technique of guided association/
guided discovery, as well a variety of related interventions. Thus, Cognitive Therapy has
a less directive and more idiosyncratic flavor than RE(B)T, although both share a com-
mon strategy of identifying and correcting cognitive distortions. Like RE(B)T and behav-
ioral therapy, Cognitive Therapy was originally ahistorical in nature, although it has
become much less so in recent years.
One of the hallmarks of Cognitive Therapy has been its constant theoretical refine-
ment, its strong reliance on the collection of empirical data, and the use of these data in
further modifying the theory and practice. Thus, it has broadened and deepened over the
years. An example is Beck’s major theoretical statement on the etiology of depression
(Beck, 1987). While still based explicitly on an information-processing cognitive
 Cognitions and Psychotherapy 421

conceptualization, he discussed six separate but overlapping models of depression. These

models include several that are distinctly developmental in nature, as well as evolution-
ary. The developmental aspect of Cognitive Therapy was enhanced further by the recent
extension into the treatment of personality disorders, leading to the central role of the
cognitive schemas in psychopathology. Schemas are cognitive structures that integrate
and assign meanings to events by screening, coding, and evaluating incoming stimuli
(Beck, Freeman, & Associates, 1990). By their very nature, they have their origins in
childhood and are constructed over many years; thus, they are developmental in nature.
Indeed, some are even referred to as Early Maladaptive Schemas (Young, 1990).
Cognitive Therapy has even been able to incorporate topics that might be seen as
belonging to other orientations. Thus, there has been recent interest in the role of emo-
tions within Cognitive Therapy (e.g., Segal, Lau, & Rokke, 1999) involving the use of
hot thoughts or heavily emotional-laden cognitions (Padesky & Greenberger, 1995), as
well as the role of empathy and other relationship factors (Burns & Auerbach, 1996). This
activity within a cognitive–behavioral explanatory framework speaks well of the inte-
grating power of cognitive psychotherapy in general.

“The Child Is Father to the Man . . .”

The developmental aspects of cognitive therapy attained primacy in the work of Vittorio
Guidano (1987), who introduced two additional concepts that soon were to become
important—motor theories of the mind and tacit knowing. Motor theories assume that the
mind is not simply an information-processing organ, but that it actively constructs reality
through its interaction with incoming stimuli and its interpretation and classifying of
these stimuli based on prior organizing cognitive constructs. Tacit knowledge consists of
deep, abstract, unverbalized rules that organize an individual’s perception of self and the
world. Guidano postulated the existence of the Personal Cognitive Organization (P.C.Org.),
the specific organization of personal knowing processes, and applied this construct to an
analysis of the cognitive organizations of a variety of psychological problems.
Michael Mahoney (1991) further developed this theme in his discussion of Core
Ordering Processes. He argued that these processes (or cognitive deep structure) are
surrounded by a protective belt that quite appropriately and wisely protects the cognitive
system itself from too-rapid change in its core constructs of personal meaning. Rapid
change can threaten the very sense of self upon which our identity is built, a deeply
frightening experience for all of us. Outside the protective belt is the surface-structure
activity that consists of our daily activities and thoughts—presumably the stuff with
which the behaviorists and early cognitivists originally were concerned.
Simultaneously, Mahoney (1995) elevated constructivism to a prominent place within
cognitive psychotherapy. Essentially, constructivism is a philosophical viewpoint that
argues that reality is socially constructed rather than representational. Thus, reality is
created by the human mind rather than a truth that is apprehended and understood. The
constructivistic model has many implications for cognitive therapy, indeed for psycho-
therapy in general. As Mahoney has stated,
Constructive metatheory, on the other hand, (a) adopts a more proactive (vs. reactive and
representational) view of cognition and the organism, (b) emphasizes tacit (unconscious) core
ordering processes, and (c) promotes a complex systems model in which thought, feeling, and
behavior are interdependent expressions of a life span developmental unfolding of interactions
between self and (primarily social) systems (1995, p. 8).
Therefore, Constructivism involves a fundamental shift from the assessment and modi-
fication of irrational (by functionally defined definitions) cognitions to an examination of
422 Journal of Clinical Psychology, April 2004

the client’s core (or tacit) assumptions and rules (meaning structures) and the co-creation
of new meaning structures. However, the fundamental guiding principle is that no indi-
vidual, neither therapist nor client, has any monopoly on truth. Indeed, the whole concept
of truth is itself socially constructed. Mahoney’s work on constructivistic approaches to
therapy represents a radical epistemological break with previous cognitive-therapy mod-
els. The search for meaning now becomes paramount.
Thomas Dowd and his colleagues have explored some of the same developmental
and constructivistic themes, although from a different vantagepoint. Dowd and Pace (1989)
used earlier work on paradoxical interventions and client reactance in arguing that ther-
apeutic models are essentially systems for the creation of meaning and that therapeutic-
change attempts often fail because they attack the problem (first-order change). Dowd
and Pace suggested that second-order change can be fostered by attacking the solution
that now has become the problem and that client psychological-reactance level (opposi-
tional behavior) is an important client individual-difference variable mediating outcome.
Dowd and Courchaine (1996) investigated the experimental cognitive-psychology liter-
ature on implicit learning and tacit knowledge and drew implications for the practice of
cognitive therapy. In brief, they found evidence that tacit knowledge is often more com-
prehensive, detailed, and richer than explicit knowledge and that much important learn-
ing occurs implicitly. Early life experiences are especially likely to be learned implicitly,
and the identification of tacit cognitive themes particularly is important in the therapeutic
process. Dowd, Pepper, and Seibel (2001) explored the developmental antecedents of
psychological reactance and found that high reactance was related to greater autonomy,
less intimacy, a lack of generativity, less trust, and less psychosocial health. No curvilin-
ear relationship was found between reactance and identity, as hypothesized. They con-
cluded that high reactance level derives from earlier developmental stages.
It is important to note the conceptual similarity among core cognitive schemas, core
ordering processes, and tacit or implicit knowledge structures. All refer to what earlier
might have been called the unconscious in that they refer to aspects of knowledge that are
outside of ordinary conscious awareness and exercise considerable and unnoticed influ-
ence on human behavior. Dowd (1997) has analyzed the difficulty in fostering human
change because of the inherent conservatism and self-protective nature of the human
cognitive system as it attempts to protect itself from discrepant information. He described
brain activity as a cognitive filter that screens out information that is discrepant with its
already-existing set of rules and assumptions and admits information consonant with
those rules and assumptions. In the process, individuals guard their sense of self-identity.
What can be learned from this examination of the evolution of the behavioral and
cognitive psychotherapies? First, it is apparent that the explanatory models have changed
considerably—from a machine model, to a linear–causal model, to an information-
processing model, and finally (though probably not conclusively) to a cognitive structur-
ally differentiated model. In the process, this therapeutic development appears to have
paralleled similar changes in the general scientific worldview. Second, the models, in
some respects, have circled back upon themselves—from an exploration of mental and
cognitive structures to an examination of overt behavior, to an examination of covert
behavior, and back to an examination of cognitive structures, although with significantly
different explanatory constructs. Thus, the Freudian unconscious can be seen as similar to
the concept of tacit (or implicit) knowledge structures. In the process, theoreticians have
oscillated between a pessimistic and an optimistic view of the possibility of rapid and
significant change. Third, it can be inferred that all explanatory models essentially are
metaphors—guiding fictions—to help therapists explain and categorize phenomena. There-
fore, Guidano’s (1987) Personal Organizational Structures and Mahoney’s (1991) core
ordering processes are no more or less real than Freud’s concept of unconscious pro-
 Cognitions and Psychotherapy 423

cesses. Likewise, Beck’s Cognitive Triad is no more or less real than Freud’s Id, Ego, and
Superego. Explanatory constructs change because the culture changes—and old meta-
phors are not as easily understood as new metaphors. Fourth, it appears that the ability of
humans to categorize and recategorize data is infinite so that the only question is what
new explanatory constructs will arise in the future. As Mahoney (1995) has noted, human
cognition is contrast dependent. Only the specific contrasts change. Fifth, it is apparent
that the number of techniques included under the heading of behavioral or cognitive–
behavioral therapy has expanded greatly.
Mahoney (1995) has provided one hint of future directions. He noted (p. 199) that,
“Issues of value, including (but not limited to) aspects of religion and spirituality, have
come to be recognized as inevitable in psychology in general and psychotherapy in par-
ticular.” Religion and spirituality, once central to human thought, have been relegated to
the periphery since the Enlightenment. Perhaps, with the recent decline in the absolute
hegemony of the western scientific–empirical epistemological worldview, and the increas-
ing interest in issues of meaning in psychotherapy and elsewhere, they once again will
become central to human thought and the creation of ultimate meaning.
Another future direction may lie in the use of nonverbal techniques. One of the prob-
lems in psychotherapy has been how to change what are essentially core (or tacit) knowl-
edge structures by the explicit knowledge techniques of verbal interventions. As Dowd and
Courchaine (1996) have noted, implicit learning is more rapid, comprehensive, and richer
than explicit learning. Nonverbal interventions such as imagery work, meditation, hypno-
sis, and behavioral experiments may be especially valuable in challenging and modifying
human cognitive structures (Dowd, 2000, 2001; Segal, Williams, & Teasdale, 2002).

The Impact of the Cognitive Revolution

As the cognitive revolution accelerated, behavioral therapists often complained that it
had added nothing new to behavioral therapy, which, they asserted, always had made use
of cognition. Some even argued that the term cognitive–behavioral therapy was an oxy-
moron. In this section, some of contributions that an emphasis on cognition added, both
conceptually and practically, to behavioral therapy will be explored. First, it expanded the
types of problems that could be treated. In the beginning, behavioral therapy was devoted
largely to the treatment of behavioral problems in institutionalized patients (via a token
economy), relatively circumscribed problems such as enuresis, and the treatment of the
neurotic disorders (anxiety). Although some researchers focused on the behavioral treat-
ment of other disorders such as depression (e.g., Lewinsohn, 1975), it was not until
cognitive–behavioral therapy developed that the range and scope of problems addressed
significantly increased. Cognitive–behavioral therapy now is applied to such disorders as
Early Maladaptive Schemas (Young, 1999) and analyses of personal meaning structures,
far from problems envisioned by the early behavioral therapists. Freeman and Dattilio
(1992) listed 36 different problems and populations to which cognitive–behavioral ther-
apy is applicable.
Second, since the advent of cognitive–behavioral therapy, the number of therapeutic
techniques included under this heading has increased dramatically. As an example, Mc-
Mullin’s (2000) handbook of cognitive-therapy techniques lists dozens of interventions,
some new and some derived from other systems of therapy. From the emphasis on vari-
ants of systematic desensitization in early behavioral therapy through the modification of
automatic self-statements in early cognitive therapy to an examination and modification
of core cognitive schemas and tacit knowledge structures, the growth in the number of
useful interventions has been very large. The armamentarium now available to the prac-
ticing cognitive–behavioral therapist is truly impressive.
424 Journal of Clinical Psychology, April 2004

Third, the conceptual and heuristic power of cognitive–behavioral therapy has exceeded
that of behavioral therapy. Concepts such as self-efficacy (Bandura, 1977) and schema-
focused therapy (Young, 1999) have added immeasurably to the theoretical literature and
have generated new interventions as well.
Fourth, the boundaries of cognitive–behavioral therapy have been expanded steadily
to the point that it sometimes is difficult to determine what is not in fact CBT. It has
begun to incorporate a constructivistic and narrative epistemological framework and has
even been proposed as an integrating theory of psychotherapy (Alford, 1995). This move-
ment has not been without its critics (see Lyddon & Weill, 1997, for an examination of
this controversy). However, if cognitive–behavioral therapy does not continue to change
and develop, it risks becoming ossified and may lose influence, as behavioral therapy did
earlier. In fact, this developmental expansion is likely an important reason why it has
become the dominant system of psychotherapy.

The Empirical Status of Cognitive–Behavioral Therapy

While cognitive–behavioral therapy consistently has been demonstrated to be more effec-

tive than a no-treatment control condition, it has not been shown to be consistently more
effective than a variety of other treatments. The following discussion is not meant to be
an exhaustive survey of the literature, but rather a brief presentation of the more impor-
tant studies. The landmark study comparing cognitive therapy and pharmacotherapy in
the treatment of depression (Rush, Beck, Kovacs, & Hollon, 1977) showed significantly
greater improvement for the former than for the latter. However, these results have not
been supported consistently. The massive National Institute of Mental Health (NIMH)
collaborative study failed to find significant differences among cognitive therapy, inter-
personal therapy, and imipramine for moderately depressed outpatients. For more severely
depressed patients, only imipramine was significantly better (Elkin et al., 1989). Nor
were there mode-specific effects for any of the three treatments (Imber et al., 1990).
None of the therapies produced any consistent effects on measures related to its theoret-
ical orientation, leading to the conclusion that there may be core therapeutic processes
operating across all treatments. Furthermore, there were no significant differences among
the three treatments after an 18-month follow-up period (Shea et al., 1992). Holroyd,
Nash, Pingel, Corgingley, and Jerome (1991) found no differences between cognitive
behavior therapy and amitriptyline in treating tension headaches, although what treat-
ment differences there were favored CBT. Hollon et al. (1992) did not find significant
differences between cognitive therapy and pharmacotherapy in treating depression, nor
were there any advantages to combining them. Black, Wesner, Bowers, and Gabel (1993)
found that fluvoxamine was more effective than cognitive therapy in the treatment of
panic disorder, although both were more effective than a placebo. Shapiro et al. (1994)
found that cognitive–behavioral therapy and psychodynamic–interpersonal psychother-
apy were equally effective in treating depressed clients irrespective of severity of depres-
sion or treatment duration, except on the Beck Depression Inventory, where CBT had a
slight advantage. Ost and Westling (1995) found equivalent effects for cognitive therapy
and applied relaxation for the treatment of panic disorder. In a very significant study,
Jacobson et al. (1996) found no significant differences among a complete cognitive-
therapy treatment (including a focus on core schemas), a cognitive-therapy treatment
focusing on automatic thoughts, and behavioral activation alone. More recently, Foa,
Rothbaum, and Furr (2003) examined the outcome literature on the treatment of post-
traumatic stress disorder (PTSD) and concluded that exposure therapy was more effec-
tive when conducted alone that when combined with other CBT procedures.
 Cognitions and Psychotherapy 425

There have been some studies favoring cognitive therapy, however. Evans et al.
(1992) found that depressed outpatients receiving cognitive therapy had a significantly
lower relapse rate than those receiving pharmacotherapy. Hollon (2003) reviewed the
outcome literature and concluded that cognitive–behavioral therapy has greater enduring
effects than other forms of therapy, especially medication, and may have preventive effects
as well. Relapse prevention effects also have been found for the Mindfulness-based cog-
nitive therapy for depression (Segal et al., 2002). Effects also have been found, for Beck,
Sokol, Clark, Berchick, and Wright (1992) found that cognitive therapy was significantly
better than brief supportive therapy in treating panic disorder. Fava, Grandi, Zielezny,
and Canestrari (1994) found that patients receiving cognitive–behavioral treatment had a
significantly lower level of residual symptoms after drug discontinuation than those patients
in a clinical management group. Unlike the Ost and Westling (1995) study, Clark et al.
(1994) found that cognitive therapy was significantly more effective in the treatment of
panic disorder than applied relaxation and imipramine at 3 months and at 15 months, but
not at 6 months. Arntz and van den Hout (1996) found that cognitive therapy was more
effective than applied relaxation at treatment end and at follow up. In a review of cognitive–
behavioral therapy of anxiety-disorders studies, Chambless and Gillis (1993) reported
that, in general, CBT was more effective than wait-list and placebo control groups, as
well as supportive therapy. Dobson (1989) conducted a meta-analysis of 28 studies and
found that there was a greater degree of change for cognitive therapy than for no-treatment
control, pharmacotherapy, behavior therapy, and other therapies. However, in a sub-
sequent meta-analysis, Dobson and Dozois (1998) found a continued advantage of cog-
nitive therapy over alternative treatments only for the Beck Depression Inventory (BDI),
and then only at the post-test assessment. Comparisons of cognitive therapy and behav-
ioral therapy showed no differential advantage for either. A combined drug–cognitive-
therapy treatment was superior to cognitive therapy alone only at follow up.
In addition, there are some indications that different outcome rates across treatment
sites in the NIMH collaborative study may have resulted in lower outcome rates for
cognitive therapy (Jacobson & Hollon, 1996). Jacobson and Hollon also argued that
studies involving pill-placebo conditions might make the results more interpretable because
they then can account for nonspecific effects. Finally, Ollendick (1998) argued that the
use of manualized treatment procedures may be one reason why cognitive–behavioral
therapy procedures have not been shown to be more effective. He found evidence that the
subsequent use of individualized treatment procedures with those who had been classi-
fied as failures using manualized treatment procedures resulted in increasing the percent-
age of individuals responding to CBT for school refusal, PTSD, and specific phobias for
animals.

Summary
It is inaccurate to say that cognitive (behavioral) therapy has added nothing to what
already was extant in behavioral therapy. The cognitive revolution has led to a tremen-
dous theoretical and technical expansion of psychotherapy practice. Certainly behavioral
therapy has been shown quite effective for a variety of disorders and is for that reason
appropriately included in cognitive–behavioral therapy. Indeed, a number of compari-
sons of the two modalities have shown equivalent outcome. However, other comparisons
have demonstrated a greater effectiveness of cognitive–behavioral therapy treatments,
and it shows promise, especially in reducing relapse, and perhaps in the prevention of
psychological problems. With the recent attempts at the integration of cognitive–
behavioral therapy and aspects of cognitive psychology (e.g., Dowd, 2002b; Dowd &
Courchaine, 1996), CBT may well be a truly integrative theory of human change.
426 Journal of Clinical Psychology, April 2004

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