American Psychological Association

110th Convention
Chicago, August 22-25, 2002

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Photo by Fenichel: Left to Right (Left of podium, Albert Ellis, Steven Hayes), Co-chairs Carole Rayburn & Cyril Franks, Arnold Lazarus, Arthur Staats, Judith Beck, Thomas Lynch

Roundtable Discussion: Will the Real Behavior Therapy Please Stand Up?

This distinguished panel was moderated in a wonderfully erudite and humorous manner, with crisp British accent, and many anecdotes, by Cyril Franks.

From existential to rational emotive to dialectical behavior therapy (DBT), and all points in between, this was one of those "you have to be there" experiences as there were a diversity of themes and perspectives. Aside from the fascinating (and grounding) historical overviews offered by Drs. Franks and Lazarus, there was a thread running through the comments and presentations which was a constant reminder that the reason for diversity and changes in approach and technique over the years is because of the role of empirical study. A subtext was some playful exploration of whether in fact one can even now speak of "behavior therapy" in the singular, as opposed to behavior therapIES (plural). Dr. Franks repeatedly argued for "data-based therapies" as the new Holy Grail to be pursued, one where the various perspectives might find a common ground.

Franks' historical overview began with the time he calls "BC - Before Conditioning", such as the 50's when psychology was deep within a "psychoanalytic morass" and there was "nothing like outcome research". Since, as he saw it, "everything had to have a name", the concept of "behavior therapy" was coined by Lazarus, though he noted that Skinner also "coined the word but never used it." For himself, Franks said that even back then "I knew the only thing that really matters" was the conditioning and behavior theory we use today, but it was Wolpe who found the first viable model to compete with the existing psychodyamic model: "desensitization". Here he suggested that the AABT should really be the association for advancement of behavior therapiES and that perhaps in the absence of "a real 'behavior therapy'" to speak of, we might rightly change the name to "Association for the Advancement of Data Based Therapies". Wondering what is really being described, given that "people look at cognition, affect, and who knows what else... I assembled the 6 most exciting people in the field who can address 'behavior therapy', even if not changing the name..."

Dr. Franks introduced the panel, pausing after introducing Ellis and Beck to wonder aloud if in fact "cognitive therapy [is] going back to compartmentalization and missing the complexity". He announced that unfortunately Marsha Linehan was not there to address DBT, but that Dr. Lynch would "be Marsha" for the day. He described the "contextual therapy" of Steven Hayes as "exciting and stimulating, though I find his theory a bit towards the mystical" and he noted in introducing Lazarus that the latter has "quietly dropped the word 'behavioral' from his 'multi-modal' therapy". Needless to say, Dr. Franks was an active presence throughout the presentation (between speakers) and was both engaging and persistent as he reflected on history, names of approaches, and the need to keep an eye on data-driven therapies. With that, he introduced the venerable Albert Ellis, who did not curse at all during this presentation, and who offered his own historical perspective.

Ellis began by explaining, "I started to create REBT in 1953 after I stopped doing psychoanalysis and was doing monographs on the 200+ types of psychotherapies." He found that most "failed to uncover the real reasons" for dysfunction and were "particularly deficient in the use of homework assignments". [This was a theme of his the day before, in his discussion with Aaron Beck -- the importance of clients working and working as a way of life, outside sessions as well. See: http://www.fenichel.com/Beck-Ellis2002.shtml for more of Ellis' approach and philosophy and/or http://www.fenichel.com/Beck-Ellis.shtml for the historic first dialogue (in 2000) between Beck and Ellis about their differences and similarities.]

Ellis recalled that on Jan.1, 1955 he began the journey of changing "rational therapy" into Rational-Emotive Therapy (RET), which was later to become REBT, "which it always was". Throughout the 1950's he was busy training others and by 1962 had established "the first popular cognitive therapy", to be followed by Beck and others. "Of course, there is no real behavior therapy", he said, as "all therapies have cognitive and feeling components".

Ellis shared that "I naturally think REBT is the most comprehensive... but it's impossible to prove empirically" for 3 reasons:

1. No form of behavior therapy is always done in the same way
2. All behavior therapy includes cognitive, behavioral, and emotive techniques, which the therapist chooses (or not) to use
3. "There are so many techniques it would take innumerable studies to demonstrate the effectiveness of use of one or another technique, or non-use..."

How would he distinguish his Rational Emotive Behavioral Therapy (REBT) from others? "REBT is somewhat different in that it forces clients to a philosophy", which includes "USA - Unconditional Self-Acceptance", allowing people to perform well "whether or not approved of by others", and hopefully also leading to "unconditional other people acceptance". A major goal is to help people "unwhiningly accept" life circumstances. Although he uses specific techniques, he believes that REBT "is also today more philosophic than it was before, and I think it will continue to be".

Finally, Ellis re-iterated the value of imparting tools which can be used to sustain therapeutic growth beyond the therapy sessions, and emphasized that REBT is particularly "adaptable to self-help and other educational endeavors besides going into psychotherapy".

Looking towards the future, Ellis first pointed out that "the entire field of psychotherapy is more eclectic since the 1980's" and that in particular "behavior therapy has become more multi-modal -- thanks to Arnold -- incorporating existential/humanistic components". He envisions the future being one where "everyone is stealing from everyone" so that "within 10 years I predict that all behavior therapies will be equally efficacious."

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Dr. Judith Beck was the next presenter, and was introduced by Franks as a formidable expert in her own rite (and not simply that other Beck's daughter!). Franks was once again playfully provocative by asking about the validity of an "Academy of Cognitive Therapy" given his skepticism about whether there is such a thing as cognitive therapy....

Dr. Beck picked up on the introduction by asking "What IS cognitive therapy?" and attempting to provide an answer. In her estimation, cognitive therapy "puts the emphasis on conceptualizing the patient in cognitive terms", looking in depth at such things as "belief systems" and perceptions. "The ultimate goal is to change patients' reactions. The goal is to help them feel better." She acknowledges that it is not always straighforward, as there may be issues of "somatic impact" such as dealing with eating disorders and other serious situations where one is displaying seriously harmful "patterns of automatized thinking". She believes a cognitive therapist "will look at behavioral strategies and can understand why they behave the way they do." She might use a primarily behavioral approach at first, especially with depression, and/or employ problem-solving techniques. Sometimes issues arise which involve medication, diet, or environmental factors (such as being in an abusive relationship) or a strategy may involve teaching effective regulation, or she might use some dialectical techniques ("although we call it other things") or even psychodynamic approaches. But throughout the variations of treatment strategy, "the similarity is the cognitive model" which underlies the conceptualization of the dysfunctional behavior. At the same time, she is very aware that "disorders differ", so that, for example, with panic disorder she might focus on the catastrophizing, while with depression the focus might be on negative perceptions and with OCD it might be on beliefs about responsibility.

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Dr. Franks next introduced Steven Hayes, to speak about "contextual therapy", proclaiming again that "I find it mystical". Dr. Hayes thus began his presentation, "Once upon a time, in a land far away...." And he proceeded to describe his version of the history of "behavior therapy".

Dr. Hayes spoke about a "first phase" of behavior therapy, where behavior therapists "revolted" against psychodynamic therapy, "and then against theoretical limitations". A second phase arrived as hard-core proponents of specific treatments "went away to lick their wounds... [and] neo-behaviorists became CBT folk". He postulated that now "we are entering a time when many of our 'phase two' preconceptions are up for reconsideration". Dr. Hayes believes that "key data do not fit existing models -- DBT, IBCT, MBCT, ACT [Acceptance and Commitment Therapy] ...." He believes that one needs to acknowledge "new wave features", which are "generally contextualistic and consciously functional. They build on the past but are recognizably new and are hard to characterize in traditional terms." Some models such as RFT "are based on new theories of language and cognition...dealing with verbal and cognitive distortions.... [Therapies which] traditionally focused on behavior-only felt incomplete. Cognitive therapy is a little better, but still is not fully addressing root causes."

In particular Hayes would emphasize the importance of mindfulness [which in fact is something Ellis identified only the day before as a commonality across cognitive therapies]. Further clarifying, Dr. Hayes explained that "It's not the irrational thoughts which harm you. It's your entanglement with irrational thoughts which harm you." He envisions therapy as a process "to help bring balance", and believes as this proceeds, "maybe we are entering phase 3".

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Now it was time to introduce a legend who (as was said) truly needed no introduction: Arnold Lazarus. Franks shared several anecdotes, including how Lazarus has held a long-time grudge against him due to Franks' repeated use of words such as "unfortunately" and "regrettably" in reviewing the earlier works of Lazarus. Now, as he turned over the podium to the distinguished speaker, Franks properly introduced him as a genuine pioneer, "30 years ahead of his time".

Lazarus returned the playful jousting, beginning by saying "I met Franks in 1963 and I have yet to recover." His historical perspective followed:

"I was talking then [1963] about the need to bring in cognition. And this was heresy to Wolpe [his mentor in S. Africa]. Wolpe was a general practitioner. He hated the term 'behavior therapy', as it invoked psychodynamic psychotherapies." While Lazarus believes "It's not what we call it, but what we do", he recalled how nevertheless "I began to fall into tremendous disfavor" after he found himself being termed as "one of those behavior-therapy types".

Lazarus described one of his vindicating moments when he was first convinced that what he was doing was effective, and saw evidence of this in greeting a high-functioning patient on the street while he happened to be walking alongside Wolpe. He recalled how earlier he had been confronted about his therapy with "a panicky, agoraphobic woman... After 6 months of desensitization, marital therapy, etc., she's doing well, but months later she's back, quivering". He wanted to know why. And then it dawned on him: "something had triggered anxiety". Having been questioned earlier about his "poor relapse rate" he concluded then that the technique was sound but that he must have been "just a shi-ty therapist". Still, Lazarus' successes continued to grow as he continued to explore the many factors at play:

"I noticed time and again, the ABC model -- Affect-Behavior-Cognition." But he felt there must be more. During efforts to follow up with patients who had "relapsed", Lazarus even questioned if "maybe the psychoanalysts were right about needing to address deeper unconscious aspects. But that's not it. Certain aspects were not focused on, and some sensory aspects were overlooked. So I went back to basic psychology, imagery ... and more... affect, sensation, cognition, interpersonal relations.... For the first time I was noticing that people were maintaining their gains." And finally, "from 1962 to now" he has been viewing behavior as multi-determined, and therapy as needing to be multi-modal.

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Franks thanked Lazarus and commented that "the problem with my friend Arnold is that I have to agree with him too much".

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Next, Tom Lynch presented on DBT, substituting for Marsha Linehan.

Not an easy subject to summarize briefly, Dr. Lynch spoke about his interest in domestic violence and "control stimuli" approaches he might have used prior to DBT, and then sought to answer the question, "What is DBT?"

Using a diagram of a circular process, Dr. Lynch presented Dialectical Behavior Therapy as an intervention which is made to address a problem behavior by intervening and blocking a pattern of "emotional dysregulation" while teaching how to regulate emotion and avoid or reduce the problem behavior. Originally developed from work with suicidality it has become widely applied to work with borderline personality disorder and now, increasingly, with multiple diagnoses.

With entrenched disorders, old paradigms simply did not work, especially with impulsive and self-destructive behavior. He gave the analogy... "If you burn your hand on the stove, you take it off. But that doesn't work here. They get some sort of control/benefit from the behavior." So DBT will attempt to teach how to regulate emotion and reduce or avoid the harmful behavior. It begins with a strategy to block the problem behavior and break the reinforcement that it has been providing. Then it is discussed, including the experience of temporary relief from a problem behavior. The "dialectical" component comes out of the knowledge that there are universalistic/formal "truths" versus relativistic. Realities may differ, for example one person seeing 30 objects before them but another person seeing 30 billion (by counting the atoms). "What does dialectics add? A third way of thinking. There are truths, but they are contextual.... For any point an opposite position can be held."

Dialectics occur through dialogue, and include:

• Logical analysis of contradictory facts or ideas (thesis-antithesis)
• A way of thinking -- the process of looking for an appropriate truth
• synthesis

One patient might say "I think drugs are good" and the therapist might reply "No, they're bad". Using dialectics the "truth" might be that "using drugs makes you feel better, but leads to problems, too". Thus, "evil versus good becomes evil and good". A treatment goal is to attain a "balance of acceptance and change" while maintaining a search for "what is left out".

[Interesting to me that there is much talk of balance and polarization, while the Borderline pathology is famously known in psychoanalytic terminology for the proclivity towards "splitting", a phenomenon which makes treatment very difficult because of the black versus white cognition, partitioned off without grey in between.]

Here Dr. Lynch told the story of a Zen master and his student. In helping someone cross a stream the master had to touch the other person, though this was forbidden behavior. The student asked how the master could have done so, to hold on to someone like that? The Zen master said that "I have let go of the person and you are still holding on." This was used to illustrate how one must "allow and let be" at times despite our inherent human instinct to intervene and "fix things".

So, "What does DBT do?"

• Reduces polarization
• Allows the therapist to give up being RIGHT but not lose their point of view
• Acknowledges that the patient influences the therapist while being influenced by the therapist etc....
• Keeps the patient slightly off balance (e.g., devils advocate, extending)

Now... "How does it work? We're not sure... exposure to cues, reacting to cues, probably problem-solving, and learning metacognitive skills..."

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The final presenter was Dr. Staats, who began with a bit of history recalling the development of the token economy (1958), use of time-outs, etc.

Unfortunately, as my own presentation was moments away and I needed to hike across the convention center to get there, I missed the tail end of this presentation. As I was leaving, I heard him talking about about "PB" using the term repeatedly - psychological behaviorism, I finally realized. For some reason -- most likely conditioning -- I felt the need for a Peanut Butter sandwich as I headed off quickly to a nearby food court.   :-)