Anxiety TCC

ANRV372-CP05-05 ARI 19 February 2009 7:29
Psychological Treatment
of Anxiety: The Evolution
of Behavior Therapy and
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Annu. Rev. Clin. Psychol. 2009.5:97-119. Downloaded from www.annualreviews.org
Cognitive Behavior Therapy

S. Rachman
Department of Psychology, University of British Columbia, Vancouver, British Columbia
V6T 1Z4 Canada; email: rachman@interchange.ubc.ca
Annu. Rev. Clin. Psychol. 2009. 5:97–119 Key Words

First published online as a Review in Advance on treatment evolution, therapy pioneers, evidence-based treatments,
December 16, 2008
psychological therapy prospects
The Annual Review of Clinical Psychology is online
at clinpsy.annualreviews.org Abstract
This article’s doi: The development of evidence-based treatments for anxiety disorders is
10.1146/annurev.clinpsy.032408.153635
a major achievement of clinical psychology, and cognitive behavior ther-
Copyright c 2009 by Annual Reviews. apy is the best-established and most widely used method. The first form
All rights reserved
of this therapy, behavior therapy, was a combination of Pavlovian and
1548-5943/09/0427-0097$20.00 Behavioristic ideas and methods and was particularly successful in re-
ducing fears. The infusion of cognitive ideas in the late 1970s generated
the wider and more flexible cognitive behavior therapy that independent
agencies in the United States and United Kingdom now recommend as
the treatment of choice for most of the anxiety disorders. Remaining
theoretical problems and clinical limitations need to be tackled.
97
NIMH (Einstein & Center 1992, Natl. Inst.

Contents Health 1991, Wolfe & Maser 1992). They also
recommend CBT for obsessive-compulsive dis-
INTRODUCTION . . . . . . . . . . . . . . . . . . 98
order (OCD; March et al. 1997). The NICE
THE EVOLUTION OF
report recommends psychological treatment,
BEHAVIORAL APPROACHES
specifically CBT with exposure and response
TO ABNORMAL
prevention, as the first-line treatment for mild
PSYCHOLOGY . . . . . . . . . . . . . . . . . . 99
and moderate cases of OCD, and the addi-
BEHAVIORISM. . . . . . . . . . . . . . . . . . . . . . 100
tion of medications in severe cases (http://
THE TREATMENT OF
www.nice.org.uk/CG031fullguideline).
ANXIETY . . . . . . . . . . . . . . . . . . . . . . . . 101
NICE recommends CBT for anxiety disor-
THE TREATMENT OF
ders (Natl. Inst. Health Clin. Excellence 2004)
OBSESSIVE-COMPULSIVE
and trauma-focused CBT for PTSD (Natl.
DISORDERS . . . . . . . . . . . . . . . . . . . . . 105
Inst. Health Clin. Excellence 2005). Reviews

REINFORCEMENT THERAPY . . . . . 105
and recommendations for the treatment of the
THE RANGE OF
other anxiety disorders (social phobia, specific
REINFORCEMENT THERAPY. . 106
phobias, acute stress disorder, and health anxi-
SOME EARLY OBSTACLES AND
ety) will doubtless follow. Given the available
DIFFICULTIES . . . . . . . . . . . . . . . . . . 107
evidence and meta-analyses of treatment ef-
DEVELOPMENTS IN THE
fects for these disorders, it is reasonable to an-
UNITED STATES AND THE
ticipate positive recommendations for psycho-
UNITED KINGDOM:
logical therapy and CBT in particular (Barlow
COMMON GROUND. . . . . . . . . . . . 109
2002, Craske 1999, Marks 1987).
THE EMERGENCE OF
The NIMH recommendations arise out of
COGNITIVE THERAPY . . . . . . . . . 110
specially arranged consensus conferences in
THE MERGING OF BEHAVIOR
which experts pool their knowledge and ap-
THERAPY AND COGNITIVE
praisals. The NICE recommendations are pre-
THERAPY . . . . . . . . . . . . . . . . . . . . . . . . 111
pared by working groups of experts who collect
PROBLEMS ENCOUNTERED BY
the evidence over a period of time and then issue
COGNITIVE BEHAVIOR
their conclusions. The conclusions are graded
THERAPY . . . . . . . . . . . . . . . . . . . . . . . . 113
for degree of confidence, and are reviewed at
SUMMARY AND CONCLUSIONS. . 114
two- or four-year intervals. Innovatively, NICE
reports also state which treatments are not rec-
ommended. A strength of the NICE procedure
is that a large database is established, which
NIMH: National INTRODUCTION provides the basis for regular reviews, assess-
Institute of Mental
Health The development of evidence-based psycho- ing new treatments, and comparing the effec-
logical methods for treating anxiety is one of the tiveness of treatments across disorders. It is
NICE: National
Institute for Health major achievements of clinical psychology. The admirably systematic and comprehensive, but
and Clinical National Institute of Mental Health (NIMH) inevitably a slow process.
Excellence (U.K.) in the United States and the National Institute This review deals exclusively with the evo-
Cognitive behavior for Health and Clinical Excellence (NICE) in lution of psychological treatments for anxiety,
therapy (CBT): a the United Kingdom function differently, but and although it includes references to some
psychological their conclusions regarding psychological treat- methods that are no longer recommended, the
treatment that
ment for anxiety are similar. Cognitive behavior main thrust is to trace and evaluate the most
combines cognitive
and behavioral therapy (CBT) and/or medications are recom- commonly recommended method, CBT. None
techniques mended for the treatment of panic disorder by of the NIMH or NICE reports on the treat-
NICE (http://www.nice.org.uk/anxiety) and ment of anxiety recommends psychoanalysis
98 Rachman
or its derivatives and hence they are not dealt ing product of this shift was the development
with here. The NICE report on OCD (http:// of effective new methods of treatment. The
www.nice.org.uk/CG031fullguideline) new methods went through three stages of de-
Exposure and
states, “there is no evidence of efficacy or velopment: behavior therapy (BT) started to response prevention:
effectiveness for psychoanalysis in the treat- emerge in the mid 1950s, cognitive therapy in a technique in which
ment of OCD” (p. 10). The report also states, the 1960s, and the two approaches merged into patients are
“Neurosurgery is not recommended in the CBT in the 1980s. encouraged to inhibit
the urge to escape
treatment of OCD” (p. 210). BT emerged in independent but parallel de-
from exposure
The development of CBT spans nearly a velopments in the United States and the United exercises or use safety
century from conditioned reflexes to catas- Kingdom during the period from 1950 to 1970. behavior to escape
trophic cognitions, and until very recently there The second stage, the growth of cognitive ther- from or avoid exposure
was a large gap between the scientific advances apy, took place in the United States from the exercises
and the dissemination of the effective meth- mid 1960s onward. The third stage, the merg- Behavior therapy
ods (Clark 2004). In keeping with the growing of behavior therapy and cognitive ther- (BT): psychological
therapy that
ing insistence for evidence-based treatments, apy into CBT, gathered momentum in the late
concentrates on
the U.K. Minister for Health announced in 1980s and is now well advanced in North Amer- modifying observable
2007 a plan for massive expansion of the pro- ica, Europe, and Australia. CBT is widely ac- behavior
vision of psychological therapy for the treat- cepted and is practiced by growing numbers Cognitive therapy:
ment of anxiety and depression in the United of clinicians; it is the most broadly and confi- psychological
Kingdom. He stated, “Psychological therapies dently endorsed form of psychological therapy treatment that
have proved to be as effective as drugs in tack- and dominates clinical research and practice in concentrates on
modifying maladaptive
ling these common mental health problems many parts of the world.
cognitions
and are often more effective in the long run” The origin of BT can be traced to Pavlov’s
(http://www.gnn.gov.uk; Oct. 10, 2007). The fundamental work on the process of condition-
government set out a six-year plan to improve ing (Asratyan 1953, Pavlov 1955). During the
matters by allocating more than 300 million course of his research on digestive processes,
pounds (approximately $600 million) in the first he observed that the experimental animals be-
three years in order to train an additional 3600 gan salivating in anticipation of receiving food,
psychological therapists in “giving evidence- and he had the perspicacity to recognize that
based treatment,” specifically CBT. The num- he was in a position to use precise experi-
ber of specially trained therapists will increase mental controls in the study of learning pro-
to 8000 within six years. A similar but less am- cesses. His initial discovery of the operation
bitious scheme is now in place in Australia: of conditioned reflexes was widely expanded,
“It is recommended that CBT be provided” or and in time, he established an experimental
any other evidence-based treatment as deemed paradigm for investigating abnormal behavior.
relevant, for 12 sessions of therapy per calen- Pavlov proved that abnormal and lasting dis-
dar year (http://www.psy.org.au/medicare/). ruptions of behavior can be produced by expos-
Rachman & Wilson (2008) discuss the signifi- ing animals to insoluble perceptual discrimina-
cance of these changes. tions or to intense stress, and he mapped out the
effects of these induced disturbances (Pavlov
1955, pp. 234–244). Moreover, this neurotic
THE EVOLUTION OF behavior showed the characteristics of normal
BEHAVIORAL APPROACHES conditioned responses, including stimulus gen-
TO ABNORMAL PSYCHOLOGY eralization, extinction, and second-order con-
As part of the movement away from introspec- ditioning. Pavlov’s provision of an experimental
tionism toward behaviorism, psychologists be- model laid the basis for the scientific study of
gan developing a behavioral approach to the how abnormal behavior, and fear in particular, is
study of abnormal psychology, and an outstand- acquired (Mineka 1985, 1987). His explanations
www.annualreviews.org • Psychological Treatment of Anxiety 99

were of course based on conditioning processes; trospectionist psychology. The most promi-
many years later, and in greatly different nent and effective proponent of behaviorism,
(clinical) circumstances, Pavlov’s work was used Watson (1983), used Pavlov’s work to account
to formulate a conditioning theory of fear ac- for the development of emotional behavior and
quisition (Wolpe 1958, Wolpe & Rachman chose the conditioned acquisition of fear as
1960). It is a curiosity that Pavlov never took an exemplar of emotional learning. For many
the logical next step, from causation to cure. decades, behaviorism was the dominant form
He advocated the therapeutic role of inhibi- of psychology: “For a while in the 1920’s it
tion, and his recommendations for treating the seemed as if all America had gone behavior-
induced and other neuroses were physical, not ist” (Boring 1950, p. 645). In 1920, Watson
deconditioning—drugs (especially bromides), & Raynor published their famous case of lit-
sleep, rest, and removal to protected shelter tle Albert to demonstrate how emotional re-
(Asratyan 1953, pp. 128–130). Pavlov classi- sponses become conditioned. A distinct fear was
fied the “congenital” temperaments of the an- established in a stable 11-month-old boy by
imals into four nervous system groups (excita- presenting him with a rat and then making a
tory, inert, active, and weak) and noted some sudden loud noise behind him. After repeating
resemblances to classical types of human tem- this sequence a number of times the child be-
peraments (choleric, phlegmatic, sanguine, and gan to display signs of fear when the rat was
melancholic) (Asratyan 1953, pp. 122, 128; introduced. This reaction persisted and then
Pavlov 1955, pp. 234–244, p. 482). He observed generalized to other stimuli. As Wolpe (1983)
that these inherited properties interact with noted, Watson planned to “treat” the boy by
environmental experiences; for example, the techniques that are echoed in modern meth-
dogs with a weak nervous system temperament ods (e.g., by counter-conditioning, modeling)
were easily disturbed by stressful stimuli or but he was unable to test out his ideas because
experiences. the child was no longer available. The signifi-
Later researchers reasoned that if neuroses cance of the demonstration of inducing a fear
can be acquired by conditioning, it should was overinterpreted, but it supported the idea
be possible to decondition them. Prominent that human fears can be conditioned, and it ulti-
among these pioneers were Gantt (1944), mately inspired the invaluable research of Mary
Liddell (1944), Masserman (1943), and Wolpe Cover Jones (1924) on the unlearning of chil-
(1952). Although it had been shown that many dren’s fears. Her enterprise made therapeutic
animals are vulnerable to neurotic behavior fear reduction seem viable and directly influ-
and that conditioning techniques are depend- enced the forms of BT that were developed for
ably capable of producing such neurotic behav- children and adults some 30 years later. After
ior, there were limitations to transferring this testing a number of possible methods, she con-
knowledge to the treatment of people. These cluded that two were reliably effective in reduc-
included the relatively primitive behavior of the ing the fears: direct conditioning, in which the
animals, the absence of speech, and an acknowl- feared object is repeatedly shown to the child at
edgment that the experimental model did not gradually increasing proximity and the child’s
and could not prove that human neuroses nec- negative reactions are dampened by associating
essarily develop in this way, i.e., by traumatic or them with pleasurable eating, and by social imi-
subtraumatic conditioning. tation of other children. Remarkably, these two
tactics still have merit and are used in many
circumstances. The graded and gradual expo-
BEHAVIORISM sures to the fear stimuli that were an implicit
Pavlov’s work had an extremely important influ- element in her direct conditioning method re-
ence on the emergence of behaviorism, which main a central feature of the current method
was largely a reaction to the stagnation of in- of exposure and response prevention. The full
100 Rachman
value of her work emerged after a dormancy of ond World War, and volunteered for the army
three decades and is an historical example that Medical Corps. In the course of his military du-
provides a spark of hope for clinical researchers ties, he developed a strong interest in the psy-
who yearn for the recognition of their unjustly chological problems experienced by the soldiers
neglected gems. and explored the effects of a makeshift form
of psychodynamic therapy that he cobbled to-
gether. After the war, he went into private prac-
THE TREATMENT OF ANXIETY tice and continued to use his dynamic meth-
The British form of BT emerged in the early ods until he grew increasingly disappointed by
1950s and concentrated on anxiety disorders in the unsatisfactory results and sought alterna-
adults. It was derived mainly from the ideas of tives. He was impressed by Pavlov’s work and
Pavlov, Watson, and Hull. The major contrib- the claims of behaviorism, including Watson’s
utors to the early growth of BT were Joseph writings on emotional learning and the famous
Wolpe, whose laboratory research on the exper- demonstration of generating a conditioned fear
imental induction of neurotic behavior in ani- in little Albert. Wolpe was strongly influenced
mals laid the basis for his fear-reduction tech- by the pioneering work of Mary Cover Jones
niques (Wolpe 1958), and Hans Eysenck, who (1924) on the elimination of children’s fears and
provided a firm theoretical structure and ra- adopted her method of repeated graded and
tionale for the new therapy (Eysenck 1960). gradual exposures to the fear stimulus.
“Neurotic symptoms are learned patterns of be- Following up Pavlov’s ideas, Wolpe began
havior which for some reason or another are searching for ways of translating the results ob-
unadaptive,” (Eysenck 1959, p. 62, emphasis in tained in research on experimental neuroses in
original). animals to the treatment of neurotic patients.
An important motive for the early at- He began to construe neuroses as learned but
tempts to develop new approaches to abnor- unadaptive behavior (Wolpe 1952). The avail-
mal behavior and treatments was the desire to able research was exceptionally stimulating, but
connect these subjects to academic psychol- none of it bridged the gap with human neu-
ogy and provide them with a firmly scien- roses. Wolpe decided to start afresh by carry-
tific foundation. The prevailing psychodynamic ing out his own research program on the in-
approaches were autonomous enterprises and duction of experimental neuroses in cats, with
had little connection with academic and scien- the clear aim of forging behavioral methods for
tific psychology. Given the academic interest in treating the conditioned fears of the disturbed
learning theories between 1930 and 1970, it was animals (Wolpe 1958). He succeeded in demon-
inevitable that attempts would be made to im- strating that the fears can be deconditioned
port the learning concepts into clinical psychol- by a program of repeated gradual and graded
ogy. In the two streams of BT that emerged in re-exposures to the conditioned stimuli that
the postwar years, psychologists in the United evoked the fear response, and thereby laid the
States were most influenced by Skinner and basis for the most commonly used method of
those in the United Kingdom by Pavlov. They fear reduction in contemporary psychological
also tried to apply the Hullian hypothetico- therapy. He accomplished this crucial advance
deductive approach to clinical matters and working in relative isolation. While continu-
hoped to gain from it a structure and ing his clinical practice, Wolpe managed to get
precision. permission to carry out his private research on
Wolpe strayed into psychological therapy animal behavior, on a part-time basis, in spare
indirectly. He qualified as a physician at the rooms on the roof of the Medical School in Jo-
Medical School of the University of Witwater- hannesburg. Having established that the fears
srand in his hometown of Johannesburg, South could be deconditioned, he explored means of
Africa, shortly before the outbreak of the Sec- facilitating the effects of the repeated exposures,

and following Cover Jones’s example, found In his classic text, Wolpe (1958) described
that the best tactic was to feed the (hungry) cats his experiments and reasoning and discussed
at each stage of the graduated re-exposure to a series of treated patients. Most of them
the fear stimuli. This finding was incorporated were treated by his major method, system-
into his theory of reciprocal inhibition—fears atic desensitization, and the clinical results
are most effectively inhibited if they are repeat- (and theoretical foundations) attracted atten-
edly evoked and then suppressed by the imposi- tion (e.g., Eysenck 1960, Lazarus & Rachman
tion of an incompatible response, which in this 1957, Rachman 1959). Few of Wolpe’s (1958)
instance was feeding (Wolpe 1958). This se- other methods, whether borrowed or invented
quence of evocation and suppression promotes (assertive behavior, thought stopping, aversion
the development of a lasting inhibition of the relief), were adopted.
fear reactions. The influence of Pavlov, who His stimulating theory of reciprocal inhibi-
emphasized the therapeutic role of inhibition, tion had explanatory value and enabled clini-
is evident in Wolpe’s construal of reciprocal in- cians to think constructively and systematically
hibition as the basis for therapy. about therapeutic problems, but it proved dif-
His next task was to apply the results of ficult to subject the theory to definitive tests
the deconditioning experiments to treating despite the clarity of Wolpe’s statements. Simi-
anxious patients. He planned to decondition larly, the conditioning theory of fear acquisition
the anxiety by repeated exposures to the fear (Wolpe 1958, Wolpe & Rachman 1960) retains
stimuli but needed to find a substitute inhibitor; some explanatory power but can no longer pro-
feeding responses were of course inappropriate vide an account of the genesis of all fears. At
and he settled on induced relaxation using the least two other pathways appear to be involved:
Jacobson method (1938). The combination of vicarious acquisition and informational acqui-
repeated graded and gradual exposures plus re- sition of fear (Rachman 1978, 1990). Expanded
laxation was refined into his primary technique, conditioning theory (e.g., Mackintosh 1983),
systematic desensitization. It proved to be effec- emphasizing the informational quality of con-
tive but somewhat impractical. His collection ditioning, has prepared the way for a more com-
of fear-evoking objects became unmanageable, prehensive theory of fear and anxiety (Rachman
and worse, many anxiety-evoking situations 1991).
were too diverse, complex, and diffuse to be Wolpe’s natural diffidence was no hindrance
evoked in a clinic. For example, evoking social to the determined pioneering work that he car-
anxiety during treatment sessions was not prac- ried out in intellectual and physical solitude,
tical, and the common disorder of agoraphobia but advocacy was not his strength. However,
could not be manipulated in the clinic. He Prof. H.J. Eysenck was a convincing and promi-
overcame this problem by substituting imaginal nent advocate of the new approach. He was the
evocations of the anxiety-producing situations dominating head of one of the largest graduate
and found that most of his patients were able research departments of psychology in Britain,
to form the necessary images; once formed, the the Institute of Psychiatry, London University,
images did indeed produce a measure of anxi- a position that he deftly used to encourage re-
ety. [Recent research (e.g., Holmes et al. 2007) search into and the teaching of BT (Eysenck
indicates that imagery is a powerful and impor- 1990). Eysenck was a learning theorist, favor-
tant element in anxiety disorders, but Wolpe’s ing Hull’s hypothetico-deductive approach, and
imperative was to find a method for reducing his major interest was in the psychology of per-
anxiety by repeated exposures to instigators of sonality. An important secondary interest was
anxiety; it is understandable, therefore, why the development of psychological treatment for
he did not use the opportunity to investigate neurotic disorders. Viewing treatment from his
the nature and significance of the emotional learning theory perspective, Eysenck was ex-
images.] tremely receptive to the early attempts at BT,
102 Rachman
and in 1960 he published an edited collection and was a potential embarrassment for an ex-
of articles in his book Behavior Therapy and pert in the psychology of personality; never-
the Neuroses. This influential publication in- theless, Eysenck wove his dimensional analy-
cluded articles on the treatment of children’s sis of personality, with its primary factors of
fears, enuresis, agoraphobia, stammering, and introversion/extraversion and neuroticism, into
asthma, and gave prominence to Wolpe’s work. his construal of BT. With the rise of CBT, in-
The collection was followed by an early text- terest in the dimensional analysis of personal-
book, Causes and Cures of Neurosis (Eysenck & ity waned and was replaced by a profusion of
Rachman 1965). In 1963, Eysenck established measures to assess cognitions. This was a logi-
the first journal devoted to the publication of cal advance, but it regrettably led to a relative
articles on the emerging new therapy, Behav- neglect of behavioral assessments.
ior Research and Therapy, now in its forty-fifth Lader & Wing (1966) proposed an alterna-
year of publication. In keeping with the re- tive to Wolpe’s explanation that was based on
search and clinical developments, articles on re- the concept of habituation. Their maximal ha-
inforcement procedures were published, but a bituation model stated that the repeated presen-
high proportion of the articles dealt with anxi- tation of a fear stimulus while the person is in
ety disorders. Although he recognized the sig- a state of deep relaxation facilitates a process of
nificant biological influences on abnormal be- habituation that is marked by steadily declining
havior (Eysenck 1967), his main argument was responsiveness to the stimulus. They suggested
that most neurotic problems are acquired by that systematic desensitization is best construed
learning processes, notably conditioning, and as a process of maximal habituation rather than
that unadaptive behavior can equally be un- a process of reciprocal inhibition as set out by
learned. Wolpe’s work epitomized his propos- Wolpe. The Lader-Wing model was plausible
als, and Eysenck therefore promoted it to the and admirably succinct and clear. It was ap-
full. Eysenck’s powerful, articulate advocacy of pealing because habituation is “the most wide-
BT was a critical element in the dissemination spread form of learning” (Mackintosh 1983),
of the new ideas and methods. offered continuity with observations from ani-
Eysenck (1960, 1985, 1990) was disdainful mal research including experimental neuroses,
of psychoanalysis and its derivatives and urged and led to specific predictions. These included
the adoption of rigorous methods of appraising the prediction that if the fear stimulus is re-
the effects of therapy. In 1952, he published a peatedly presented while the person is in a
critique of the claimed effects of psychotherapy state of high arousal, little habituation will oc-
and concluded from his negative findings that cur. Also, it could be deduced that any method
fresh alternatives were needed. His unceasing of ensuring that the person remains in a state
advocacy of the need to shift toward empirical of low arousal during the repeated presenta-
investigations was an early plea for evidence- tions will be effective, regardless of whether
based psychological therapy. Eysenck’s radical the low arousal was ensured by pharmacologi-
views on the prevailing psychodynamic thera- cal or psychological means. These and similar
pies were contested, and he was criticized for predictions received support, and the construal
being out of touch with clinical management. of fear-reducing methods in terms of habitu-
It is correct that he was a theoretician, and he ation was simple, straightforward, and help-
lightly replied that he had once treated one ful. However, the model was applicable only
patient for one session. The man had a sex- to those fear-reducing methods that are based
ual problem that was successfully resolved by on repeated exposures and has less relevance
an ad hoc lesson in anatomy (Eysenck 1990). for other methods, including CBT methods.
The criticism that BT was mechanistic and Moreover, the maximal habituation model of
failed to take into account the individual char- fear has an awkward weakness. As pointed out
acteristics of particular patients had some merit by David M. Clark (personal communication,

1988), there is no independent measure of Theorists attempted to explain the persis-

habituation. The occurrence of habituation is tence of anxiety and unadaptive behavior in ad-
inferred by the reduction in fear responding, dition to its genesis, and Mowrer’s (1960) ex-
and this circularity frustrates attempts to vali- planation of the “neurotic paradox” proved to
date the model. Nevertheless, the notion of ha- be extremely useful. He set out a two-stage
bituation remains a useful way of thinking about model of fear and avoidance and argued that
and planning exposure treatments of fear. avoidance behavior persists precisely because it
Lang (1968, Lang & Lazovik 1963) de- is successful—at least in the short term. Any
veloped an experimental model for rigorously avoidant or other behavior that reduces anxi-
evaluating and refining systematic desensitiza- ety will be strengthened. This model was timely
tion. Working with participants who had spe- and fitting, and behavior therapists exploited its
cific phobias, generally a fear of snakes, Lang explanatory value (Eysenck & Rachman 1965).
convincingly demonstrated that desensitization It was used to explain the genesis and main-
is a viable method and effectively reduces fear. tenance of significant anxiety and of “unadap-
He developed an original tripartite method for tive” avoidance behavior, notably in agorapho-
assessing fear that comprised psychophysiolog- bia. The limitations of the explanation, and its
ical changes, behavioral avoidance tests, and implications for the use of the response preven-
verbal reports. All three measures showed re- tion method, began to appear in the 1970s. Not
ductions after desensitization, but interestingly, all avoidance behavior is driven by fear; people
they were not always correlated. This led Lang engage in avoidance behavior for a variety of
to introduce a fresh and constructive view of reasons that include discomfort, disgust, impa-
fear. He argued that fear is not a palpable lump tience, or simple convenience. Avoidance be-
but instead it consists of three loosely coupled havior is also a common and important means
components: physiological reactivity, behavior, of gaining and maintaining a sense of safety
and verbal report. It was later observed that (Rachman 1990).
during treatment, and at other times, the three Much of the attention of early behavior
components change at different rates; they can therapists was focused on the treatment of
change desynchronously, and this casts a dif- agoraphobia because it was, and is, a common
ferent light on the relation between fear and disorder and because it lent itself to the pre-
courage (Rachman 1978, 1990). vailing behaviorist approach (Eysenck 1960,
Curiously, while Lang was collecting exper- Mathews et al. 1981, Thorpe & Burns 1983,
imental evidence of the fear-reducing effects Wolpe 1958). For some years, agoraphobia
of Wolpe’s method of systematic desensitiza- was regarded as the prototypical neurosis. It
tion, based on repeated imaginal presentations, fitted easily into the behavioristic approach
a shift was taking place in clinical practice. Clin- because it is easily construed as a form of
icians reverted to using exposures to real objects persistent, unadaptive observable avoidance
and situations, described oddly as “in vivo ex- behavior, and a major feature of experimental
posures.” The reasons for this change were not neuroses is observable avoidance behavior.
made explicit but probably were a combination The early treatments were explicit attempts
of the undoubted tedium of lengthy courses of to change the patient’s behavior. The behavior
systematic desensitization and a sense that in was observable, measurable, manipulable, and
vivo exposures are superior. Wolpe worked in hence ideal for the behavioristic approach.
private practice and found it impractical to ar- The advances made in the exposure treat-
range in vivo exposures, whereas hospital clin- ment of specific phobias were a simple step
icians had superior resources. Most of the re- from the laboratory experiments of Lang
finements and improvements in the methods of (1968), much of whose treatments dealt with
treating anxiety took place in hospitals, clinics, a fear of snakes, as did the research of
and university laboratories. Bandura (1969, 1977a). Moving beyond the
104 Rachman
early version of learning theory, Bandura at- venting them from carrying out any of their
tached importance to the social-cognitive fac- anxiety-reducing compulsions, such as repeti-
tors in treatment and was the first experimenter tive washing or checking. This required inten-
ERP: exposure and
to develop a fear-reduction method—namely, sive, continuous care in order to ensure that response prevention
participant modeling—that surpassed system- the patients completely refrained from the com- treatment
atic desensitization. He proved the effectiveness pulsive acts (e.g., in order to prevent compul-
of therapeutic modeling and introduced the sive washing, the water supply was cut off when
concept of self-efficacy (Bandura 1977b), which necessary). They were given sympathetic sup-
was advanced as an explanation for the effects of port and encouragement throughout. The ERP
most treatments, especially those involving fear was partially successful, and Meyer’s example
reduction. was followed, albeit in a less-demanding, less-
Therapeutic modeling has proven effica- intensive form, in the treatment of outpatients
cious in the treatment of specific phobias, as (Rachman et al. 1979, Rachman & Hodgson
illustrated by the research of Ost (1989). In re- 1980). Meyer was influenced by the success of
cent years, the treatment of phobias has been so-called flooding treatments in extinguishing
so refined that effective one-session treatments fears in animals and had the boldness to try
are now available (Ost et al. 2001). Investiga- it on patients where other clinicians hesitated.
tors are examining the efficacy of the fascinat- His results aroused attention, and the method
ing virtual-reality treatments, which promise to was refined and eventually evaluated in a ran-
improve techniques for treating acrophobia and domized control trial that demonstrated that
claustrophobia, at least (e.g., Emmelkamp et al. ERP with modeling is moderately successful in
2002). treating OCD (Rachman et al. 1979). Further
progress awaited the adoption of cognitive con-
cepts and methods.
THE TREATMENT OF Steady progress was made in expanding the
OBSESSIVE-COMPULSIVE new treatments to other forms of anxiety dis-
DISORDERS order. Effective treatments are now available
Obsessive-compulsive disorder (OCD) is a for social anxiety (Clark et al. 2006, Clark &
complex mixture of cognitive and behavioral Fairburn 1997, Clark & Wells 1995, Heimberg
problems that did not lend itself to behavior- et al. 1995) and generalized anxiety disorder
ist treatment, not least because BT was abso- (Dugas & Robichaud 2007). There is also sound
lutely behavioral and cognitions were not on evidence of the therapeutic value of BT and/or
the agenda. Wolpe (1958) had limited success CBT for a range of specific phobias that in-
in treating OCD, and the application of his cludes claustrophobia, snake phobia, dog pho-
method of desensitization was lengthy and la- bia, acrophobia, and spider phobia (Barlow
borious. In 1966, Victor Meyer tried out an ex- 2002). The techniques have been so refined that
ploratory treatment in the management of two one-session treatments are often effective (Ost
patients in the Middlesex Hospital (London) 1989, Ost et al. 2001). At present, these are the
who were severely disturbed by OCD. They only evidence-based methods for treating spe-
were treated during protracted inpatient care by cific phobias.
a method that later acquired the label of “expo-
sure and response prevention” (ERP). Meyer
was an extraordinarily committed and consci- REINFORCEMENT THERAPY
entious clinician who had a good deal of ex- While these events were taking place in the
perience treating agoraphobia, and he took the United Kingdom, psychologists in the United
bold step of trying out a “total” treatment that States were pushing ahead with the application
consisted of exposing the patient to the most of Skinnerian ideas and techniques to clini-
upsetting OCD items/situations and then pre- cal problems. Skinner’s (1959) forceful writings

and fascinating demonstrations of the power of ness.” Instead, the disorders were redescribed in
reinforcement procedures encouraged attempts purely behavioral terms, such as “verbal behav-
to replicate the effects of operant condition- ior deficits,” “disruptive behavior,” and so on.
ing, so readily achieved with pigeons and other (For the sake of clarity and narrative flow, the
laboratory animals, with psychiatric patients. terms that were conventionally used for these
In one of the earliest attempts, by Lindsley disorders at the time are retained here.)
(1956), a replica of a Skinner box, complete with
the familiar lever and delivery chute, was con-
structed for research on psychiatric problems. THE RANGE OF
The hope and intention was to shape and re- REINFORCEMENT THERAPY
shape the behavior of the patient by systematic For institutional and theoretical reasons, the
operant conditioning in the box. As in research U.S. and U.K. psychologists turned their
with animals, tangible rewards were delivered attention to different samples and different
whenever the patient emitted a constructive re- problems. The American psychologists tried
sponse, but rewards were withheld after the to improve the behavior of people with severe
emission of a disruptive response, such as in- psychiatric disorders, such as schizophrenia,
coherent rambling. The underlying ideas were manic-depressive disorders, childhood autism,
that the abnormal behavior of the psychiatric developmental disorders, and self-injurious
patients was the result of an inappropriate con- behavior. Some of these intrepid early re-
ditioning history and that the abnormal behav- searchers, such as Ayllon (1963) and Ayllon
ior could be reshaped into normal forms by pro- & Azrin (1968), chose to work with the most
viding the correct reinforcement contingencies. severe cases: patients who lived in the back
By arranging for the patient’s adaptive behav- wards of large dismal psychiatric hospitals and
ior to be followed by reward, the psychologist whose condition was conventionally believed
could reshape the patient’s abnormal activities. to be chronic and unchangeable (Eysenck &
It was essentially a matter of ensuring that ap- Rachman 1965). The primary method con-
propriate behavior was followed by rewarding sisted of arranging appropriate reinforcement
consequences and that inappropriate behavior procedures, and the approach was described
was extinguished by withholding rewards. This as “behavior modification” instead of therapy
seemingly simple approach was often used with (Kazdin 1978). Much of their research was
ingenuity (Ayllon & Azrin 1968). inventive. Ayllon and Azrin helped to lay the
The entire medical model, with its concepts basis for what became known as token economy
of “psychiatric disorder,” “abnormal behavior,” systems, which are systematic programs of
and “mental illness,” was thrown overboard, reinforcement for appropriate behavior and the
and a new vocabulary was introduced. The pa- omission of reinforcements for inappropriate
tient’s disorder was redefined as the person’s be- behavior. (Tokens, originally plastic discs, were
havior problem, pure and simple, and the solu- introduced as readily dispensable and usable
tion lay in providing a corrective program of markers of reinforcement that the patients
operant conditioning. The later introduction were able to exchange for tangible material
of the term “behavior therapy” to this Skin- rewards, such as sweets, cigarettes, and mag-
nerian form of therapy was accurate. The term azines.) The earliest token-economy systems
was less precise when applied to the British were established in psychiatric institutions
version of therapy, in large part because most and later introduced into other institutions
clinical psychologists in the United Kingdom such as schools, homes for delinquent youths,
worked within the National Health Service, hostels, and hospitals for mentally handicapped
in which the medical model of mental prob- people. Prominent work carried out in this
lems prevailed. Skinnerian researchers scrupu- period included Lindsley’s (1956) reshaping
lously avoided using terms such as “mental ill- of verbal responses in psychiatric patients,
106 Rachman
Krasner’s (1958) expansion of the scope of and varied manifestations of neuroses (mainly
verbal conditioning, and Lovaas’s (1961, 1987) anxiety disorders) were put down to faulty con-
extraordinarily persistent work on modifying ditioning, and few attempts were made to ex-
autistic behavior. However, little attention was plain why one patient developed agoraphobia
paid to neurotic problems, nowadays classified and another obsessive-compulsive disorder, or
mainly as anxiety disorders. The British social phobia, and so on. This weakness had
clinical researchers worked on treatments for two consequences: The approach was too gen-
agoraphobia and disorders of anxiety among eral to allow exact testing of the main proposi-
otherwise intact, functioning adult outpatients. tions of the overall theory, and it did not pro-
In summary, the U.S. psychologists were mote the development of specific treatments for
Skinnerian in outlook, strictly behaviorist in specific problems. For some period, the well-
their conceptions and language, regarded psy- established exposure-and-response prevention
chological/psychiatric disorders as problems of method was used across the board, for virtually
faulty learning, concentrated their efforts ex- all clinical problems.

clusively on behavior, and worked mainly with In common with their American colleagues,
people who had severe, intractable problems. the British psychologists construed many
They espoused an unqualified environmental- psychological/psychiatric disorders as the prod-
ism and described themselves as “behavioral en- uct of faulty learning. However, they acknowl-
gineers” who engaged in behavior modification, edged biological contributions to the disor-
not therapy. ders (Eysenck 1967) and espoused a qualified
environmentalism in which neurotic disorders
SOME EARLY OBSTACLES were regarded as the product of environmen-
AND DIFFICULTIES tal events, learning experiences, and condi-
The British contributors were influenced by tioning in particular. But even these learning
learning theory, but few were strongly attached processes were thought to be influenced by
to the views of a specific theorist and were un- inherited properties, and some people were
receptive to Skinner’s ideas (1959), which they believed to be particularly vulnerable to neu-
tended to reject as narrow and unhelpful. There roses (consistent with Pavlov’s views on tem-
was a quiet reverence for the ideas and find- perament; Asratyan 1953).
ings of Pavlov, and the two leading contributors, BT provoked intense opposition from clini-
Eysenck and Wolpe, both favored the Hullian cians and members of the medical profession. It
learning theory, a hypothetico-deductive the- was argued that the radically new therapy was
ory that offered precision and scientific formal- simplistic, and some critics warned that it might
ity and was widely subscribed to at the time do significant harm, even sending patients into
(Hull 1943). An attractive possibility was to ex- a psychotic state. There was a lengthy debate
tend Hull’s theory to clinical problems in the about whether the reduction of the mere symp-
hope of developing a quantitative hypothetico- toms would be followed by symptom substi-
deductive model of abnormal behavior with tution. From a psychodynamic point of view,
an unquestionably scientific appearance. How- with its emphasis on underlying and often un-
ever, this hope was not fulfilled. Today very conscious causes, this was a legitimate concern.
few clinicians know or care about the learning Consequently, searches for signs of symptom
theories; nevertheless, such theories may have substitution were undertaken but yielded little
served as scaffolding. evidence of the predicted substitutions. Instead,
A weakness of BT that was not apparent it was often found that after the successful re-
early was a lack of specificity. The construal duction of avoidance behavior and verbal re-
of clinical problems as essentially the result of ports of anxiety, for example, in agoraphobia,
faulty learning, especially conditioning, had un- patients had improved in other ways (e.g., were
doubted merit but left much unsaid. The many less depressed).

However, the critics were correct in describ- tion. Regrettably, this mistaken belief that the
ing BT as simplistic. As subsequent develop- fear structure must be evoked in order to reduce
ments revealed, the theories of causation, such the fear (e.g., Foa & Kozak 1986) tended to dis-
Exposure therapy: a
technique in which as a purely conditioning theory of fear acqui- courage the development of new methods, in-
patients are repeatedly sition, were insufficient. It was recognized that cluding cognitive methods. Fear can be reduced
exposed to cues and in addition to conditioning, fear could be ac- in many ways without planned, sustained, pro-
situations that evoke quired vicariously and by negative/threatening longed, and repeated exposure (Rachman 1990,
excessive fear
information (Rachman 1977, 1990, 1991). The p. 237). These examples include (a) Bandura’s
behaviorist theory of the causation of neuroses (1969, 1977a) work on informational means
was too general and relied almost entirely on a of changing fear, (b) by developing perceived
traumatic conditioning model that had its ori- self-efficacy (Bandura 1977b), (c) the frequently
gin in Pavlov’s demonstration of the genesis of observed (untreated) reduction of fear after
experimental neuroses. The neglect of cogni- successful treatment of comorbid depression,

tive factors in explaining causation and persis- (d ) the common occurrence of spontaneous re-
tence and in formulating treatments ultimately missions of anxiety disorders, (e) the reduc-
proved to be a serious limitation that was finally tion of other but untreated fears in successfully
addressed by the infusion of cognitive concepts treated cases of anxiety disorders, and ( f ) re-
into BT in the 1970s. ductions after placebos. Additional means for
The growing success of exposure ther- fear reduction include anxiolytic medications,
apy led to a confusion between this particular social skills training, applied relaxation, stress
method of reducing fear and the concept of BT, management procedures, interpersonal ther-
and for a period, the terms “exposure therapy” apy, and problem solving (Rachman 1990). Fear
and “behavior therapy” were erroneously used can also be reduced by cognitive therapy (e.g.,
as synonyms. BT has a wider span and includes Barlow 2002, Booth & Rachman 1992, Clark
reinforcement techniques, Bandura’s (1977b) et al. 2006, Clark & Fairburn 1997).
self-efficacy procedures, social skills training, Many early advocates of BT, especially those
applied relaxation, and other nonexposure who endorsed the views of Skinner (1959), gave
techniques. The expansion into CBT, with an wholly environmentalist accounts for the be-
emphasis on cognitive techniques that include havior problems, but these explanations were
reductions in inflated feelings of responsibility, not sustainable. Methodologically, the virtual
corrective techniques for catastrophic misin- exclusion of evidence that was not based on ob-
terpretations, reordering of memories, and so servable behavior also proved to be unsustain-
on, led to a more balanced view of the place able. For example, the attempt to get around
of the exposure technique. Strictly speaking, this self-imposed prohibition led to the descrip-
exposure therapy means the repeated, planned, tion of people’s thoughts and feelings as “verbal
deliberate, hierarchically graded, prolonged reports,” or worse, “private events.” Using the
exposure to situations/stimuli that evoke fear. latter term when interviewing patients suffering
The resort to explanations that depended on from intense anxiety (“tell me about your pri-
putative incidental exposures to fear-evoking vate events”) risked some misunderstandings.
situations was tempting, but these explanations As BT absorbed cognitive concepts, the assess-
confused matters and were rarely testable. ment of psychological problems expanded be-
The many convincing examples of the effec- yond its original behavioral limitations. Ulti-
tiveness of exposure treatment (Barlow 1988, mately, this turned out to be an overcorrection,
2002; Marks 1987) led to the widespread adop- as the focus on cognitions led to a neglect of
tion of this method—almost to the exclusion behavioral measures.
of other techniques. For some time, it was be- The overwhelming majority of early ther-
lieved that exposure was not merely sufficient apists were psychologists, and as such, they
but also a necessary condition for fear reduc- encountered strong objections from many
108 Rachman
psychiatrists in addition to academic and sci- States a few years after publishing his book,
entific criticisms. Many physicians, including Psychotherapy by Reciprocal Inhibition (1958). The
some in positions of authority and power, were anxiety-reduction methods were absorbed and
totally opposed to the provision of therapy by improved in the United States, notably by
people who were not medically qualified. A Bandura and Lang, but the Skinnerian rein-
profound and testy disagreement between the forcement model and techniques initially had
professions rumbled on for years, and the early limited impact on U.K. psychologists.
behavior therapists had to be satisfied with a se- In contrast to their counterparts in the
ries of small victories. The professional barrier United States, the British group was critical
to BT gradually faded in the face of the grow- of Skinner’s ideas and used broadly behavioral
ing success of the new therapy, especially as ideas and methods. They first tackled adult neu-
the medical profession had little to offer people rotic disorders, and attention was concentrated
with anxiety disorders. The massive expansion on developing methods for reducing anxiety,
of psychological therapy services in the United such as systematic desensitization. They de-
Kingdom, aiming to produce 8000 new psycho- voted little or no attention to chronic psychi-
logical therapists within the next six years, hints atric illnesses or to the difficulties of people
at the winners of that early professional dispute. who were intellectually handicapped until sig-
nificant progress had been demonstrated in the
United States.
DEVELOPMENTS IN THE The separate development of early BT in the
UNITED STATES AND THE United States and the United Kingdom was fol-
UNITED KINGDOM: lowed by a merging of the two approaches, at
COMMON GROUND least in terms of aims and most methods. The
American and British psychologists construed strong adherence to a Skinnerian framework re-
psychological problems as problems of behav- mained confined to the United States and even-
ior and believed that it was necessary and usually tually faded even there. The Skinnerian frame-
sufficient to change the affected person’s behav- work’s total rejection of the medical model and
ior. Both groups regarded psychological prob- its introduction of new terms left some traces
lems as problems of faulty learning; the problem but in the main has also faded.
was regarded as one of surplus behavior or of In the period from 1970 to 1980, there was
deficient behavior, and it needed to be corrected a consolidation of the early advances and a shift
by changing the behavior. Both groups were at- from innovative ideas and techniques to the
tempting to apply behavioral science to psycho- business of evaluating the claims of therapeu-
logical/psychiatric problems, both espoused the tic efficacy. Outcome studies abounded, to the
use of strict scientific standards, and both were subsequent delight of dedicated meta-analysts.
participants in the march of empiricism. Overall, the commitment to empirical, applied
As the efficacy of behavioral therapy steadily science led to the development of increasingly
improved and many patients were seen to bene- refined, stringent criteria methods for evalu-
fit, increasing numbers of clinical psychologists ating therapeutic effects. Behavior therapists
adopted the methods in the United States and played a leading role in establishing these de-
the United Kingdom. At a conference on men- manding standards, many of which have now
tal health held in St. John’s Wood in London become common coin.
in 1961, some American (Lindsley, Ayllon, and In the first decade of BT, there was a good
Franks) and British (Eysenck, Wolpe, Gwynne deal of theorizing, and grand designs were of-
Jones, and Rachman) behavioral psychologists fered, but the emphasis gradually shifted to
met to exchange ideas and experiences, and col- technical topics, notably to the assessment of
laborative work followed. This process was fa- therapeutic efficacy. The shift from theory to
cilitated when Wolpe immigrated to the United practice was natural and marked a victory of

sorts. The adoption of empiricism, one of the Two of the pioneers of cognitive therapy,
“inward workings of the age,” transformed the Beck (1967, 1976, 1993) and Ellis (1958, 1962),
methods of clinical psychology, and BT became shared the view that most psychological dis-
one of its “outward facts.” However, the ab- turbances arise from faulty cognitions and/or
sence of progress in theorizing about BT in the faulty cognitive processing, and that the rem-
period 1970–1990 gradually became a source of edy is to be found in corrected appraisals
discontent. In addition, there was a second and and corrective actions. Both of their forms of
more practical need to expand the search be- therapy are directed at correcting faulty pro-
yond the essentially behavioral techniques that cesses/cognitions, both concentrate on present
characterized the first stage of this new type of problems and present thinking in contrast to
psychological therapy. The early and consider- the historical dredging of earlier forms of
able successes in reducing anxiety and overcom- psychotherapy, and both recommend behav-
ing unadaptive avoidance behavior, as in agora- ioral exercises. (Ellis and Beck both started
phobia, for example, were not accompanied by out as psychodynamic therapists, and even
successes in dealing with depression, the other Wolpe’s earliest clinical techniques were psy-
major component of negative affect. Many adult chodynamic; there was little choice at the time,
patients complain of a mixture of anxiety and and unsatisfied therapists such as Beck, Ellis,
depression. and Wolpe forged their own tools.)
In the mid 1960s, Beck “became famil-
iar with BT and incorporated many principles
THE EMERGENCE OF from this approach” (Beck 1993, p. 13). Beck
COGNITIVE THERAPY and Ellis regarded the behavioral exercises as
Given the lack of progress in treating depres- means of obtaining new, corrective informa-
sion and the waning prohibition against using tion, and in this sense, they differed from the
cognitive concepts, many behavior therapists behavior therapists who regarded the behavior
followed Beck’s work (1976, 1993) with growing changes as the essence of therapy rather than
interest, reassured in part by the inclusion of be- one of several secondary methods of producing
havioral assignments in his program. They were change. The debate about interactions between
also impressed by his insistence on accurate cognitions and behavioral change continues.
and repeated recording of events and the self- Beck’s rationale was that “an individual’s af-
correcting nature of the program. Setting aside fect and behavior are largely determined by the
the hesitations they had about the acceptabil- way in which he structures the world” (Beck
ity of nonbehavioral cognitive concepts, behav- et al. 1979, p. 3), and the therapeutic tech-
ior therapists began treating patients with cog- niques were designed to “identify, reality test,
nitive therapy. Early successes were reported, and correct distorted conceptualizations and
and these helped to remove the remaining in- the dysfunctional beliefs (schemas) underlying
hibitions about cognitive therapy, at least when these cognitions” (Beck et al. 1970, p. 4). Ellis
used alongside BT and with an emphasis on the (1958, 1962) was an early and assertive advo-
behavioral components of cognitive therapy. cate of a directive form of cognitive theory that
Paul Salkovskis, a leading behavior therapist he originally described as rational psychother-
who absorbed Beck’s cognitive concepts and be- apy, a term he later expanded into rational-
came a major contributor to the growth of CBT, emotive psychotherapy. He argued that “emo-
acknowledged the debt to Beck: “There can tional or psychological disturbances are largely
be no doubt that Beck’s cognitive approach to a result of (the person) thinking illogically or
the understanding and treatment of emotional irrationally; and that he can rid himself of most
problems represented a paradigm shift, and that of his emotional or mental unhappiness. . . and
paradigm has truly shifted” (Salkovskis 1996, disturbance if he learns to maximize his ra-
p. xiii). tional and minimize his irrational thinking”
110 Rachman
(Ellis 1962, p. 36). In Ellis’s view, “people are ysis, and behavioral changes. The tendency of
uniquely rational as well as uniquely irrational,” cognitive therapists to refer “solely to con-
and “their difficulties largely result from dis- sciously experienced thoughts and images. . .
torted perception and illogical thinking” (Ellis clearly diverges from the much wider use of
1962, p. 36). Despite his early construal of psy- the term in cognitive psychology. There, it is
chological problems, including anxiety, in terms assumed that the majority of cognitive process-
of cognitive dysfunctioning and his recognition ing is not experienced as consciously accessible
of the power of behavioral change, the work of thoughts or images” (Teasdale 1993, p. 340).
Ellis did not attract as much research and clin- Whatever the debt of CBT to cognitive psy-
ical attention as did that of Beck. The scien- chology, the contribution of BT and CBT to
tific status of Ellis’s work lagged behind Beck’s cognitive psychology tends to be overlooked.
(Kendall et al. 1995). This difference can be Starting from Pavlov’s work, clinical research
traced in part to the form of their writings. has contributed to the understanding of emo-
By comparison with Beck, the writings of Ellis tions and fear in particular, and it has con-
were more anecdotal and loosely formulated. In tributed to an understanding of the interaction
addition, the thrust of Beck’s early work was on between fear and memory and between fear and
understanding and treating depression, a clini- attention. Clinical research is also contributing
cal problem that remained essentially unsolved to our understanding of imagery and to the re-
by behavior therapists. It was therefore under- lation between imagery and memory. For ex-
standable that clinicians, even those who were ample, it has been established that attentional
using behavioral techniques for the manage- biases operate during emotional experiences,
ment of anxiety and other clinical problems, that emotional memories are primed, and that
should turn to the work of Beck for guidance in significant memories, at least those involving
trying to help people overcome depression. It recall rather than recognition, often are mood
is, however, ironic that CBT has made a greater related, if not entirely mood dependent (e.g.,
contribution to the treatment of anxiety disor- M.W. Eysenck 1992, Williams et al. 1997).
ders than to depression. The development of
behavioral activation for the treatment of de-
pression is a late but welcome turn ( Jacobson THE MERGING OF BEHAVIOR
et al. 1996). THERAPY AND COGNITIVE
Although cognitive therapy was developed THERAPY
during a time in which psychology as a whole The adoption of cognitive concepts into ther-
was moving in the direction of cognitive ex- apy was facilitated by the major shift toward
planations, there is a gap between these two cognitive psychology that was taking place in
movements. The early claims of connections psychology in general and by a growing dis-
between CBT and cognitive psychology were satisfaction with the narrowness of behavior-
statements of hope rather than fact and were ism. There was a desire among clinicians to pay
perhaps exaggerated. Teasdale observed, “The more attention to the humanistic concerns of
development of cognitive therapy for depres- their patients. Strict behaviorism left no place
sion has proceeded largely in isolation from ba- for the content of the patient’s anxieties, and
sic cognitive science” (Teasdale 1993, p. 341; clinical conversations were often regarded as
see also Seligman 1988). Cognitive therapy and distractions from the need to measure and mod-
cognitive psychology share a general outlook, ify the unadaptive observable behavior. The
but there are few similarities in terminology time was ripe for a cognitive-behavioral form
or methodology. Cognitive therapy (and CBT) of therapy, and the two streams, cognitive and
involves attempts to analyze and correct con- behavioral, were brought together by Clark’s
scious thoughts by the collection of informa- (1986) cognitive theory of panic disorder.
tion, behavioral experiments, intellectual anal- Barlow’s (1988, 1997, 2002) comparable model

was formulated independently and made an in- Salkovskis’s (1985) original cognitive analy-
valuable contribution to the development of sis of OCDs was another important contribu-
CBT. For ease of exposition, this account of tion to CBT. He showed the value of expanding
events and their significance focuses on the beyond the existing behavioral analyses to take
work of Clark and his close collaborator, P. account of the person’s interpretations of their
Salkovskis. This review concentrates on the thoughts and feelings about their compulsions
events and ideas that shaped CBT and is not an and obsessions. Additionally, he singled out the
evaluative review of the current state of knowl- crucial role that feelings of inflated responsibil-
edge about the efficacy of particular treatments. ity play in many OCD cases. By focusing atten-
Prior to the introduction of Clark’s (1986) tion on the explanation that the affected per-
explanation of the nature and causes of episodes son provides for his/her obsessive compulsive
of panic, the occurrence of these episodes urges, behaviors, and motives, Salkovskis filled
was regarded as an epi-phenomenon associ- an empty stage. Previously, the nature and sig-
ated mainly with agoraphobia. Hence, panics nificance of the specific content of the obses-
were not treated directly but rather were ex- sions and compulsions remained unexamined.
pected to fade out when the agoraphobia was As a result of Salkovskis’s analysis, researchers
treated. Klein’s (1987) original biological anal- and clinicians became acutely interested in, and
ysis of panics elevated them to a problem in attuned to, the patients’/clients’ explanations,
their own right, and Clark’s (1986) theory was understanding, wishes, and fears. Prior to the
an attempt to give an alternate psychological ex- infusion of cognitive ideas into this field, ob-
planation. “Panic attacks result from the catas- sessions were regarded, indeed defined, as un-
trophic misinterpretation of certain bodily sen- wanted, intrusive thoughts (plus images and im-
sations” (Clark 1986, p. 462), such as a shortness pulses). But the precise content of the unwanted
of breath, pounding heart, and dizziness. These thoughts was of little interest. Thanks to the in-
sensations are interpreted as being signs of im- fluence of cognitive therapy, the content of the
minent danger, most commonly of a serious thoughts is now of central importance in deal-
threat to one’s health—”I am having a heart ating with obsessions (Rachman 2003). This de-
tack” or “I am going into a coma.” The immedi- velopment confirms the historical connection
ate cause of the panic is a threatening cognition. between cognitive therapy and phenomenolog-
It follows that disconfirmations of these ical psychopathology ( Jaspers 1963).
cognitions should eliminate the panics. Clark The work of Clark and Salkovskis provided
(1988, Clark et al. 1994) presented evidence the basis for increasingly specific explanations
to support his theory: Patients do report such of the various anxiety disorders and corre-
cognitions, the proposed sequence of events spondingly specific treatments. These expan-
from sensations to cognitions to panic is con- sions include theories of post-traumatic stress
firmed, and the derived treatment is effective. disorder (Ehlers & Clark 2000), social pho-
The evidence pertaining to the theory that has bia (D.M. Clark & Wells 1995), obsessions
accumulated during the past 20 years is mainly (D.A. Clark 2004, Rachman 2003), compulsive
confirmatory, but some difficulties have been hoarding (Frost & Hartl 2003, Steketee & Frost
encountered (Barlow 2002, Clark 1988, Craske 2003), and health anxiety (Salkovskis & Clark
1999, Rachman 1990). Clark’s succinct theory 1993, Salkovskis & Warwick 1986, Warwick &
is of historical significance because it became Salkovskis 1990). Similar to Clark’s panic the-
a model for the cognitive analysis of various ory, Salkovskis & Clark’s (1993) theory reinter-
manifestations of anxiety, and the effectiveness preted the outdated concept of hypochondriasis
of the therapy derived from Clark’s theory was as “health anxiety,” in which the anxiety is pro-
impressive. The success of the theory and ther- voked and maintained by catastrophic misinter-
apy helped to launch the use of CBT for anxiety pretations of certain bodily sensations. How-
disorders. ever, unlike panic, in which the feared event is
112 Rachman
imminent (“I am having a heart attack and will tions. However, one is nevertheless left to pon-
die”), in cases of health anxiety, the dreaded mis- der why the direct modification of the negative
fortune is distressing but not imminent. More- cognitions was not more effective than the indi-
over, the provoking bodily sensations in health rect effects of exposure. In some recent studies,
anxiety tend to be persistent, even chronic, and a superiority of CBT over exposure has been
give rise to extensive and intensive safety behav- demonstrated (Clark et al. 2006), and although
ior. There is a cognitive overlap between panic these are important, cognitive behavior thera-
disorder and health anxiety, but each disorder pists still need to address the reasons for sig-
has distinctive features. nificant cognitive improvements in anxiety that
In the process of merging BT and cognitive appear after treatments that do not explicitly
therapy, the behavioral emphasis on empiricism target the negative cognitions. There is some
was absorbed into cognitive therapy. The be- evidence of a dose-responsiveness relationship
havioral style of conducting empirical outcome between CBT and cognitive change. In an out-
research was adopted, with its demands for rig- come study by Clark et al. (1994), panic patients
orous controls, statistical designs, treatment in- who received added, direct cognitive therapy
tegrity and credibility, and so forth. In turn, had a superior therapeutic outcome to those
cognitive concepts were absorbed into BT, and who received indirect treatments.
cognitive therapists attached increasing empha- In analyzing the treatment of anxiety, as in
sis to behavioral experiments and exercises. the treatment of depression, one obstacle to se-
vere tests of the theory arises from the need for
control over the timing of events. If the reduc-
PROBLEMS ENCOUNTERED tions in negative cognitions are no more than
BY COGNITIVE BEHAVIOR correlates of panic reduction or if the cognitive
THERAPY changes follow rather than precede the reduc-
Notwithstanding the remarkable advances that tion of panic, it is necessary to study the se-
it has promoted, the CBT approach to anxi- quence of events with care. Reductions in fear
ety disorders is not without problems. It has are easier to observe and record, but they can
proven difficult consistently to demonstrate the occur slowly, over weeks rather than minutes.
therapeutic superiority of CBT over BT, and In cases of panic, the measures typically range
in several instances, the therapeutic effects of over days or weeks (e.g., the number of pan-
the traditional exposure-and-response preven- ics recorded per week or even per month). So
tion method equaled those of CBT. For exam- if the patient records a decrease in panics, say
ple, in Margraf & Schneider’s (1991, Margraf from four per week to one per week, when ex-
1995) study of panic disorder, the patients who actly did this decline take place?
received pure exposure treatment without cog- Cognitions are evanescent and difficult to
nitive manipulations showed improvements as assess reliably. Furthermore, cognitive changes
large and as enduring as the patients receiv- can be difficult to track. In many instances, clin-
ing pure cognitive therapy in which exposures ical or experimental, the cognitive shifts are
were excluded. Moreover, the cognitions de- slow to develop, changing over weeks rather
clined to the same extent in both groups. It ap- than minutes. It is not possible to determine
pears that negative cognitions can decline after precisely when the change occurred, assum-
a direct treatment or after an indirect treatment ing that there is a complete change in the first
such as exposure. One possibility that has been place. Cognitive changes can initiate a process
raised is that with each exposure, the patient ac- of behavioral change that only becomes evi-
quires fresh disconfirmatory evidence (e.g., no dent some time later. The cognitive processes
heart attack, did not lose control). The accu- set in motion during a CBT session often have
mulation of this personal, direct disconfirma- their effects at some point between sessions.
tory evidence weakens the catastrophic cogni- In this sense, CBT sessions appear to initiate

emotional processing (Rachman 1980, 1990) patients with anxiety disorders, notably OCD,
that reaches completion only after an interval can be despairingly tenacious.
in which the fearful person may have had no Despite the difficulties, Clark’s (1986) the-
contact with the phobic situation and usually ory of panic increased our understanding of
cannot recall having made deliberate attempts panic. The phenomenon now is seen to be co-
to facilitate the fear reduction between sessions. herent, to be psychologically understandable.
An illustration of this type of delay in the effects In many cases, studies, and experiments, it is
of CBT was reported during the experimental now possible to make good sense of a per-
reduction of claustrophobia described by Booth son’s thoughts and fears and how they connect.
& Rachman (1992). Salkovskis’s cognitive analyses of obsessive-
There are also broader problems of causal- compulsive problems and health anxiety have
ity, and the results of CBT are open to alter- been similarly valuable.
native interpretations. In the view of Seligman It is no surprise that the cognitive anal-
(1988), the decline in cognitions and in bod- yses of hypochondriasis and of panic disor-
ily sensations after the successful treatment of der are similar, given their common ances-
panic disorders is open to more than a single try (Salkovskis & Clark 1993). The cognitive
interpretation. The declines in cognitions and theory of hypochondriasis (now sensibly re-
bodily sensations may produce the reduction of named as health anxiety) shares the boldness
the panics, but it is not easy to dismiss the pos- that characterizes the theory of panic disor-
sibility that the declines in cognitions and in der. It is argued that “bodily signs and symp-
bodily sensations are consequences of the re- toms are perceived as more dangerous than
duced episodes of panic and not the cause. It they really are, and that a particular illness is
is also possible that the decline of cognitions is believed to be more probable than it really
a correlate of the reduction in the episodes of is” (Warwick & Salkovskis 1990, p. 110). The
panic. Some critics have suggested that the cog- panic theory pertains to expectations of immi-
nitions and their decline may be epiphenomena nent catastrophe (e.g., “I am having a heart at-
(e.g., Seligman 1988, Wolpe & Rowan 1988). tack”). The hypochondriasis theory pertains to
Seligman (1988) incisively questioned why threats to one’s health or well-being that can be
people defend their irrational and unadaptive catastrophic but are more remote (e.g., “This
appraisals with such tenacity. Why do patients bump on my skin will develop into a cancer”).
with anxiety disorders, such as panic, con- The underlying mechanisms are assumed to
tinue to believe in their irrational catastrophic be common to both disorders. A major fea-
interpretations of their bodily sensations de- ture of hypochondriasis (health anxiety) is the
spite repeatedly disconfirmed expectations— great difficulty that sufferers have in absorbing
“why does the panic victim still believe he or and accepting medical evidence, and ironically,
she will have a heart attack in spite of 1000 ex- the current treatment is itself evidence based.
tinction trials?” (Seligman 1988, p. 328). The Hypochondriacal beliefs and cognitions are ir-
probable explanation for this apparent anomaly rational and tenacious.
is that in these cases the fear of a heart attack The cognitive approaches to obsessions,
does extinguish. It is then replaced by a fear phobias, social anxiety, post-traumatic stress
of experiencing a distressing episode of panic, disorder, and health anxiety share a common
and that cognition is intermittently confirmed. core that is derived from the theory of panic.
Nonetheless, the tenacity of the irrational, un-
adaptive cognitions about fear and danger that
are postulated to generate and sustain anxiety is SUMMARY AND CONCLUSIONS
a critical problem that remains to be explained. The successful development of psychological
On similar lines, the extraordinarily inflated treatment for anxiety disorders has improved
feelings of responsibility encountered among health care for many thousands of people, and
114 Rachman
the recent massive expansion of services for panic-fear—unusually in this field, an avowedly
people in the United Kingdom and in Australia causal model.
will doubtless encourage comparable improve- In turn, the advances in understanding the
ments elsewhere. Clinical psychologists and nature of fear and anxiety contributed to more
clinical researchers have provided the means satisfactory accounts of the growing list of anx-
for a significant and expanding improvement iety disorders as well as to the diagnosis and
in mental health care. assessment of the disorders. For example, de-
The developers of these methods also made scriptions of the various manifestations of OCD
other contributions. They provided a power- improved in tandem with the developing meth-
ful rationale for the slowly developing profes- ods of treatment; the nature and causes of fears
sion of clinical psychology, which was restricted of contamination are better understood, as are
mainly to psychometric assessment up until the nature and causes of obsessions. The growth
the 1950s. This restriction was based largely of CBT spawned a need for measures of mal-
on the not entirely unreasonable grounds that adaptive, fearful cognitions in order to plan
psychologists were not trained to carry out treatment protocols and to assess the outcome
therapy and because of the view of some mem- of therapeutic trials. This has proved to be a dif-
bers of the medical profession that psycholo- ficult task because the cognitions can be evanes-
gists should not be allowed to receive such train- cent and in many cases are so idiosyncratic as to
ing. However, as evidence of the fear-reducing evade measurement. It is difficult to produce
effects of psychological therapy, notably BT, cognitive measures that are psychometrically
began to accumulate, the opposition to non- sound and also clinically significant.
medical therapists carrying out treatment weak- In addition to the difficulties involved in
ened. The medical options were minimal. Ma- producing sound and significant cognitive mea-
jor proponents of the developing psychological sures, the measures tend to be somewhat insen-
treatments were strict academics who argued sitive to therapeutic changes. In CBT, thera-
from the start that rigorous standards should peutically important changes in cognition can
be applied to the emerging ideas and meth- occur slowly and over a protracted period, and
ods. Their search for empirical evidence and this complicates attempts to grasp the cognitive
enthusiasm for control trials laid a firm basis for changes that mediate clinical improvement. In
the current insistence on evidence-based treat- BT, a major index of change was the observable
ment, an insistence that is central to recommen- reduction in avoidance behavior, usually mea-
dations for psychological therapy that are pre- sured by standard behavior tests. These changes
pared by the relevant agencies, such as NICE were accessible and observable to the therapist
and the National Institutes of Health. during exposure sessions, but they had limita-
Another contribution that arose out of the tions. As Lang (1968) persuasively argued, three
developing methods of treatment was a greatly components comprise fear, and avoidance be-
enhanced and exceptionally interesting con- havior is only one of them. There were fewer
ception of the nature of fear—the methods measurement problems in BT, but the over-
were, after all, methods for reducing fear. In- reliance on avoidance measures could be mis-
evitably, the clinicians and researchers met leading. Measures of avoidance behavior were
puzzles and problems, and pioneers such as mainly useful when the treatment was expo-
Peter Lang (1968) introduced new and fasci- sure based and used for dealing with phobic
nating ideas about fear—fear is not a lump, conditions.
but rather is a loosely connected set of com- Exposure treatment, a term that was some-
ponents. Another stimulating construal, about times used interchangeably with the term “be-
prepared fears, was introduced by Seligman havior therapy,” is undoubtedly effective for
(1971), and Clark (1986) introduced the first dealing with some disorders, and partly for this
cognitive explanation of episodes of intense reason the erroneous notion took hold that

exposure treatment is not only sufficient but A major objection to cognitive construals
is also necessary. As mentioned above, fears was discussed by Teasdale (1993) and Seligman
decline in many circumstances and with var- (1988), who pointed out the gaps between cog-
ious methods that do not involve exposure nitive psychology and cognitive therapy, al-
treatment. Despite their fear-reducing effects, though it should be mentioned that findings
exposure-and-response prevention treatment from CBT have made useful contributions to
can be so demanding and upsetting that un- cognitive subjects that include attention and
acceptably large numbers of sufferers decline memory, among others. Interestingly, cognitive
the treatment or drop out prematurely (e.g., therapists have not let this significant objection
Foa et al. 2005, Wilhelm & Steketee 2006). interfere with the development of their meth-
The return of fear after a successful reduction ods and ideas. It might prove limiting in due
is another problem, as is the limited general- course.
ization of the treatment effects. However, the Another objection is that in many early
main drawback of ERP was its limited range comparisons between the therapeutic effects
and limited acceptability. A significant histori- of CBT and the prevailing exposure methods,
cal example of ERP’s limits and how they were few differences were found. Recently CBT has
overcome by the introduction of a cognitive proved superior in some instances, but the ques-
model for panic (Clark 1986) is described above. tion of why it has been difficult to demonstrate
Other historical examples include the advance this superiority remains to be answered.
brought about by the introduction of a cogni- At a deeper level, insufficient progress has
tive model of hypochondriasis (which was re- been made in answering Seligman’s (1988)
named health anxiety) in the process of recon- question: Why are unadaptive fearful misinter-
strual, and the cognitive account of obsessions. pretations so tenacious?
SUMMARY POINTS
Achievements
1. Effective psychological methods have been developed for treating anxiety disorders.
2. Increasingly specific explanations of the various forms of anxiety disorder have been
formulated.
3. Improved means of disseminating the new treatment techniques have been promoted.
Anticipated Developments
1. Cognitive analyses and procedures will be expanded to all branches of medicine; for
example, clinical reasoning, psychological factors in chronic pain, and preparation for
intrusive/painful procedures.
2. Further research will be conducted into the tenacity of abnormal, unadaptive fearful
beliefs and reasoning.
3. The nature and modification of delusions will be examined.
4. The processes involved in fear-reduction will be researched.
DISCLOSURE STATEMENT
The author is not aware of any biases that might be perceived as affecting the objectivity of this
review.
116 Rachman
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Annual Review of
Clinical Psychology
Contents Volume 5, 2009

Construct Validity: Advances in Theory and Methodology

Milton E. Strauss and Gregory T. Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

Item Response Theory and Clinical Measurement
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Carrie E. Bearden, Anna J. Jasinska, and Nelson B. Freimer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p49
Statistical Methods for Risk-Outcome Research: Being Sensitive
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Psychological Treatment of Anxiety: The Evolution of Behavior
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The Past, Present, and Future of HIV Prevention: Integrating
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Mary Jane Rotheram-Borus, Dallas Swendeman, and Gary Chovnick p p p p p p p p p p p p p p p p p p 143
Evolving Prosocial and Sustainable Neighborhoods and Communities
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Five-Factor Model of Personality Disorder: A Proposal for DSM-V
Thomas A. Widiger and Stephanie N. Mullins-Sweatt p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 197
Differentiating the Mood and Anxiety Disorders: A Quadripartite
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When Doors of Perception Close: Bottom-Up Models of Disrupted
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vii
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The Treatment of Borderline Personality Disorder: Implications

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Development and Etiology of Disruptive and Delinquent Behavior
Rolf Loeber, Jeffrey D. Burke, and Dustin A. Pardini p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 291
Anxiety Disorders During Childhood and Adolescence:
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Ronald M. Rapee, Carolyn A. Schniering, and Jennifer L. Hudson p p p p p p p p p p p p p p p p p p p p p p 311
APOE-4 Genotype and Neurophysiological Vulnerability

to Alzheimer’s and Cognitive Aging
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Depression in Older Adults
Amy Fiske, Julie Loebach Wetherell, and Margaret Gatz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 363
Pedophilia
Michael C. Seto p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 391
Treatment of Smokers with Co-occurring Disorders: Emphasis on
Integration in Mental Health and Addiction Treatment Settings
Sharon M. Hall and Judith J. Prochaska p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 409
Environmental Influences on Tobacco Use: Evidence from Societal
and Community Influences on Tobacco Use and Dependence
K. Michael Cummings, Geoffrey T. Fong, and Ron Borland p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 433
Adolescent Development and Juvenile Justice
Laurence Steinberg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 459
Indexes
Cumulative Index of Contributing Authors, Volumes 1–5 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 487

Cumulative Index of Chapter Titles, Volumes 1–5 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 489
Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org
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ANRV372-CP05-05 ARI 19 February 2009 7:29

Cognitive Behavior Therapy

Annu. Rev. Clin. Psychol. 2009. 5:97–119 Key Words

NIMH (Einstein & Center 1992, Natl. Inst.

Inst. Health Clin. Excellence 2005). Reviews

www.annualreviews.org • Psychological Treatment of Anxiety 99

www.annualreviews.org • Psychological Treatment of Anxiety 101

www.annualreviews.org • Psychological Treatment of Anxiety 103

1988), there is no independent measure of Theorists attempted to explain the persis-

www.annualreviews.org • Psychological Treatment of Anxiety 105

faulty learning, concentrated their efforts ex- all clinical problems.

www.annualreviews.org • Psychological Treatment of Anxiety 107

experimental neuroses. The neglect of cogni- successful treatment of comorbid depression,

www.annualreviews.org • Psychological Treatment of Anxiety 109

www.annualreviews.org • Psychological Treatment of Anxiety 111

www.annualreviews.org • Psychological Treatment of Anxiety 113

www.annualreviews.org • Psychological Treatment of Anxiety 115

www.annualreviews.org • Psychological Treatment of Anxiety 117

Jones MC. 1924. Elimination of children’s fears. J. Exp. Psychol. 7:382–97

Rachman S, Hodgson R. 1980. Obsessions and Compulsions. New York: Prentice

www.annualreviews.org • Psychological Treatment of Anxiety 119

Contents Volume 5, 2009

Construct Validity: Advances in Theory and Methodology

Milton E. Strauss and Gregory T. Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1

The Treatment of Borderline Personality Disorder: Implications

APOE-4 Genotype and Neurophysiological Vulnerability

Susan Bookheimer and Alison Burggren p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 343

Cumulative Index of Contributing Authors, Volumes 1–5 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 487

An online log of corrections to Annual Review of Clinical Psychology articles may be

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