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James Pretzer January 31st, 2005 10:59 PM

A few more thoughts
First, note that when I talk about cognition occurring on a level that is non-conscious and automatic, I'm not talking about non-conscious language I'm talking about cognition that is not mediated by language and that generally operiates outside of awareness. These are the appraisal processes that Richard Lazarus discussed in his 1966 book. I believe that cognitive psychologists have researched these processes quite a bit over the intervening years and that Lazarus' research holds up well.

We're not talking about the Freudian unconscious where psychoanalysts argue that formerly conscious thoughts, feelings, memories, and impulses are repressed through various defense mechanisms. We're talking about basic cognitive processes that have been around long before humans developed language.

You may be right in saying that Ellis doesn't talk about this. At the moment I'm talking about Beck's point of view.

Second, we're not moving in the direction of declaring that this is all an art, not a science. This discussion is based on a large body of research, or actually several bodies of research. Cognitive psychologists have done decades of laboratory research into the basic cognitive processes involved, social psychologists have done quite a bit of research into social cognition that is also quite relevant, clinical psychologists and psychiartists have done literally hundreds of outcome studies (go to for a concise summary). Part of the problem is that there is more relevant research than one can easily keep track of, another part of the problem is that many clinicians know little about the basic research that provides a foundation for CBT. NIMH published a good overview titled Basic Behavioral Science Research for Mental Health: A National Investment (NIH Publication #96-3682). I believe the url for it is however, I can't connect to it at the moment.

Third, you are quite right to be skeptical about subjective assertions that a particular therapy "works." However, with CBT I'm not simply expressing subjective convictions or being impressed by a few remarkable case examples. We have a large body of outcome research that show that CBT produces real changes that last. It is true that many of these studies are done by proponents of CBT but there also are many done by teams that include proponents of other approaches and a few studies done by critics of CBT.

Finally, I'm not circumventing your question about whether the presence of basic affects at birth proves that affect is primary. I haven't had time to get to that one yet but I plan to. Unfortunately, tonight it is late and the book I need to cite is upstairs but I'll try to get to that question soon.

James Pretzer February 2nd, 2005 10:47 PM

Is affect primary because it develops first?
Doug wrote, "All that aside for a moment (not to mention all the other questions you've raised!!!), is it not important to consider that developmentally 'affect' came first. That has to hold some weight, doesn't it?? Our biological equipment introduces "affect" way before conscious language emerges. Unless one believes that conscious cognition develops apart from affect, we have to slow down here, don't we? And again, and I'm not espousing any particular theory here, how you can tease apart affect and cognition . I don't think you can. Of course, 'defining affect' is maybe the first important task."

If you define "cognition" as conscious language, then obviously affect comes first. However, if you define cognition in this way then infants and children don't have any cognition until they develop language. However, research in developmental psychology makes it abundantly clear that cognition occurs in infants and children long before they develop language. Remember that conscious language is just one small part of cognition, at least as far as CT defines the term.

For a good discussion of the relationship between cognition and emotion from a developmental perspective, see Children's Emotions and Moods: Developmental Theory and Measurement by Michael Lewis and Linda Michalson (1983, pp. 49-93). Lewis and Michalson summarize the different approaches to understanding emotion (physiological, cognition causes emotion, emotion comes first, etc.) and how they hold up both philosophically and empirically. They conclude "In short, the data indicate that simple linnear models of the relationship between cognition and emotion [i.e. thoughts cause feelings or feelings preceed cognition] are inadequate. The relationship between these domains is quite complex, is continuous, and is more finely tuned than is usually depicted by traditional models. In conceptualizing the relationship between emotion and cognition, neither process should be described as causing the other. Rather, the best model is of two processes continually and progressively chasing each other, weaving their separate strands of behavior into a single composition not unlike that of a musical fugue" This is roughly what I've been trying to express, though I haven't been that fluent. I haven't discussed this with Dr. Beck yet, however I think he'd agree strongly.

Yes, it is not easy to study affect and cognition in infants. One experiment was done with 5 24-week-old infants (three boys and two girls). Infants sat in an apparatus that delivered a reinforcing stimulus (a color slide of a smiling infant accompanied by the "Sesame Street" theme song) triggered by an armpull on the part of the infant. Cognition was assessed by computing learning curves while emotion was assessed by coding facial expressions, vocalizations, and expressive behaviors such as gaze aversion. The results showed a more complex relationship between cognition and emotion than predicted by either the "thoughts cause feelings" model or the "emotions preceed cognition" model.

Doug William February 3rd, 2005 10:58 PM

Re: What uncertainties do we face in CT/CBT?
Yes, I understand (and in rethinking this I am familiar with this idea that cognition does not simply imply conscious thought). Of course, I'm still left wondering about the 'relative' simplicity of CT work when one considers trying to have a lasting impact on mental life that entails this constant stream of affects, mood, cognitions, inner life (the discussions and fantasies people have with themselves), interpersonal/familial transactions, perceptual transactions with the world at large, the long and short term memories that interact with all of this---much of it driven by automaticity). It is hard for me to shake the idea that attempting to intervene and create change-- and more importantly-- maintain those changes--- to be daunting. And yet when I read the posts here and review a lot of the archived posts, there is a kind of directness and again, simplicity and 'this is how it is' that disturbs me!! Like the word "schema"--I suspect that if we did nothing else but examine the 'ins and outs' of that word that there is a kind of nominalism at work here--- and yet the word is presented as if it implies some certain understanding of what we a talking about. But okay--I'm beginning to read Dr. Beck's book again, and I'll see if I can settle down about this a bit!!!

A separate issue I've wondered about has to do with the proclivity of the brain to revert back to previous patterns---to use old jargon--- the compulsion to repeat----just when we think that change looks like it has taken hold. Has CT taken a long term look at whether this happens? By long term, I mean going back to see previous patients 2, 3, 4 years later to examine the longevity of the changes?? I would be interested in reviewing that literature.

Thanks again for your time and patience with this!

Doug William March 8th, 2005 09:59 PM

Re: What uncertainties do we face in CT/CBT?
Dr. Pretzer??

Have I reached the end to your responses about this??


James Pretzer March 11th, 2005 11:15 PM

Re: What uncertainties do we face in CT/CBT?
No, you haven't reached the end of my responses. It's just a matter of my finding time to respond and this isn't always easy.

You wrote "I'm still left wondering about the 'relative' simplicity of CT work when one considers trying to have a lasting impact on mental life that entails this constant stream of affects, mood, cognitions, inner life (the discussions and fantasies people have with themselves), interpersonal/familial transactions, perceptual transactions with the world at large, the long and short term memories that interact with all of this---much of it driven by automaticity). It is hard for me to shake the idea that attempting to intervene and create change-- and more importantly-- maintain those changes--- to be daunting."

I don't think I've ever argued that attempting to intervene and create long-term change is simple. Effective psychotherapy is not at all simple, no matter what one's theoretical orientation. Cognitive Therapy has the advantage of using a relatively simple vocabulary and having a theoretical framework which makes if fairly simple to conceptualize many problems and develop a promising treatment plan. However, this does not mean that it is simple to implement that plan effectively.

For example, I was lecturing on the treatment of obsessive-compulsive disorder today. From a CT perspective it is fairly simple to describe what we need to do in treatment:
  1. conduct a good evaluation (and confirm that we are indeed treating OCD, not some other problem that superficially resembles OCD)
  2. establish a collaborative relationship
  3. develop a thorough understanding of the client's obsessive thoughts, compulsions and rituals, and their fears regarding what will happen if they don't engage in their compulsions and rituals.
  4. share our conceptualization of their OCD and the rationale for exposure-based treatment (i.e. facing anxiety-provoking stimuli, refraining from their usual avoidance behavior and anxiety-reduction strategies, and tolerating the anxiety until it peaks and subsides)
  5. address their fears, beliefs, and assumptions cognitively in order to get to the point that they are willing to follow through on exposure-based treatment
  6. implement exposure and response-prevention persistently until their OCD subsides
  7. develop and implement a relapse prevention plan
Unfortunately, just because it is simple to say what we need to do this doesn't mean that it is simple to do this effectively. I've been treating OCD for more than 20 years and still find it to be challenging.

Your question about long-term follow-up is a good one and highlights one area of uncertainty we have to contend with. Most outcome studies use a 12-month follow-up and there are a limited number of studies with longer follow-up periods. What data we have is encouraging and there are a few studies that show that improvement is often maintained for years. However, given the proclivity of humans to slip back into old habits, it would be useful to have more long-term follow-ups.

Because it is expensive, difficult, and time-consuming to do this kind of research, it may be a while until we know how well the results of CBT persist years after treatment. I find both the available data and my clinical experience encouraging but much more research is needed.

Doug William March 12th, 2005 06:32 PM

Re: What uncertainties do we face in CT/CBT?
Dr. Pretzer--I do understand that you are a very busy psychologist!! My query about us being 'finished' was only because I noted that you had posted quite a number of other replies since we last corresponded.

Has it ever become an issue in conducting CBT research, that individual therapists because of their own particular communicative styles and qualities of relatedness to other people, end up producing quite different outcomes (because of these nonspecific effects?). Is CBT standardized enough so that these therapist variables don't confound outcome studies? I suspect that university supervisors have asked themselves this question many times. Is the CBT being practiced 'out there' close enough to what supervisors want?? Do we know? Are training centers confident that once certain procedures are consistently applied that CBT is really the 'same thing' depending on who is doing it!! My long held suspicion even with CBT is that these 'non-specific' factors may end up being critically important, and that we need to spend much more time looking at what factors make for good matching between patient and therapist.

The more CBT pays attention to 'communicative' issues within the therapy, the more this question will be raised. The patient's 'perception' of the relationship was, of course a major area of concern to the analytically trained therapist, as was whether the patients 'psychological defenses' were being respected in the conduct of the therapy. I hope we will discuss more here, what you will be presenting at Cape Cod. I wish I could attend, but don't think that will happen.

Again--I very much appreciate the time you take out of your schedule to participate here.

Oh--Please!! If there are students currently in training, your comments here would greatly enrich this discussion!! The questions I raise here, should be ones that any of you could meaningfully comment about! So please participate!!


James Pretzer March 19th, 2005 10:07 PM

Non-specific factors in CT/CBT
Yes, you're right in suggesting that non-specific factors play an important role in all approaches to psychotherapy, including CT and CBT. Most works written on CBT presume that it is necessary to establish a good therapeutic relationship before starting to use cognitive-behavioral interventions.

In writing about CT, Beck has emphasized the importance of establishing a collaborative relationship and has gone into some detail about the therapeutic relationship. If you take a look at the Cognitive Therapy Checklist (I believe it is Appendix A in Cognitive Therapy of Depression) it gives a pretty good picture of the type of relationship he sees as being conducive to CT. Another good option is to look at Denise Davis & Jesse Wright's article about the therapeutic alliance in CT (cited in the archives at or Zindel & Segal's book Interpersonal Process in Cognitive Therapy.

It is important to note that if a therapist is using CT techniques without establishing a good collaborative relationship and a strong therapeutic alliance, they aren't doing good CT. The techniques don't work nearly as well without a good therapeutic relationshp.

Micah Perkins March 26th, 2005 11:09 AM

Re: What uncertainties do we face in CT/CBT?
I know that I am kinda jumping in the middle of things here. But, I thought that I would make some comments anyway (although, I am sure that I will not be as eliquent as some of the other members of this group:)

As far as research, I think that research can only go so far. The human psyche is very complex. Also, like what has been pointed out, different therapist have different styles... no matter how much they may try to implement the procedures in the same way. Also, clients react to therapists different (for example if a woman who was raped by a male, gets a male therapist... she may not respond to him as well as if she was working with a female therapist). I know that these studies try to control for these things, but, issues like transference can be very subtile. So... studies are good, but there are no perfect studies. Having said that, I believe that CBT has shown to be the "best" validated psychotherapy around. Does this mean that other therapies dont work. No. Other therapies do work. Ellis (albert- rebt founder) has discussed how other therapies do (obviously) work but that he believes that they work because they change the clients beliefs (although, indirectly). He just thinks that REBT (and CBT) more directly address these beliefs than do other therapies and are (usually) quicker and more helpful.

Is CBT- REBT easy. No, we all have very strong beliefs which we continually reinforce. Changing beliefs and behaviors is difficult business. CBT may easily explain what is happening, but the actual work is very difficult. There seem to be no "quick fixes" no matter what some seminars and workshops may advertise.

Is the therapeutic relationship essential? I do believe that it is VERY IMPORTANT to have a good working relationship in psychotherapy. But, does one HAVE to have a relationship to change ones beliefs. No. Look at all of the self help books and tapes on REBT- CBT. The client doesnt really have a relationship with the therapist on the tape, they are receiving new information, evaluating their beliefs, and changing their beliefs without a "relationship" in the traditional sense of the word.
When I was a child my family never wore seat belts. But, when I was in high school I watched one film in drivers ed class about people who were killed who didnt were seat belts. Based upon that information I changed my long held belief and have worn my seat belt EVERY DAY since I watched that film. No "relationship' was needed, I just changed my belief based upon the (very gross) information that I was given.

Hope this post was pertenent. Forgive me if I was off base :)

chris jones March 31st, 2005 04:20 AM

Re: What uncertainties do we face in CT/CBT?
Regarding the "primacy" of affect or cognition, I liked the dual interacting streams metaphor several posts back and the idea just put forward that we artificially carve up biological processes in order to comprehend them - leaving us confused.

Describing two dynamic biological processes as streams (of thought and affect) which interact by "setting the context or state" for the next moment in the other stream (and vice versa) is a mental model that seems more truthful than a static box-and-arrow model and that preserves the distinction necessary to do cognitive therapy. I wonder if there are some useful mathematical tools to help model these two dynamic and interactive processes.

The problem is (and this also speaks to the assertion that "affect is first") that perception has to be included and distinguished from cognition in the model. It seems to me that the model has to start with "pure perception" at some (early) point in development... and then we need some developmental framework to account for the increasing and yet variable influence of memory, automatic and conscious association upon perceptual events (as well as the affective influence). So I think the two-stream model works, but the cognitive stream needs some extra work. It seems to me that including and developing a distinction between "pure" and "influenced" perception would be helpful and important to the clinician. What we're after is a model that is pretty accurate and more importantly, that helps us do effective therapy.

Distinguishing between "automatic" and conscious is also important, but not sufficient - for there are automatic and relatively "influenced" or "distorted" appraisals (which are of course impacted by the conscious work of CT despite being automatic) and there are conscious and relatively veridical perceptual events...

James Pretzer April 18th, 2005 09:48 PM

Long-term outcome in CT/CBT?
Earlier in this discussion Doug William asked about the long-term results of CT & CBT given humans' proclivity to revert back to old behaviors. This is indeed an area where all approaches to psychotherapy face quite a bit of uncertainty. Long-term follow-ups are difficult and expensive to do (given the high level of mobility in our culture, simply finding the subjects 5 years following treatment is difficult) and therefore these studies aren't done very often.

Steve Hollon wrote a brief article (reference below) where he discusses a couple dozen studies that he sees demonstrating that CT has enduring effects. However, many of these studies involved one- to two-year follow-ups. I don't know of any studies with a 10- or 20-year follow-up other that one case of CBT for agoraphobia with an 11-year follow-up.

It certainly is reasonable to think that improvement is likely to persist in the long run if it persists through the first year or two since there are a number of problems where the risk of relapse is highest during the period immediately following treatment and decreases over time. However, not everything that is reasonable is true.

My clinical experience is that on the rare occasions when I hear from a former client years after the conclusion of treatment, it often turns out that they have maintained the gains they made in therapy. However, it is important not to place too much emphasis on a few case examples. It is quite possible that the clients who do well in the long run are most likely to refer their friends and relatives to me, to send me a note a few years after treatment, or to say "Hi" if they see me in public.

Data about the long-term outcome of various treatment options would be quite useful. My bet is that the long-term results aren't yet as good as we'd like, but that CT/CBT would compare quite favorable with other treatment options.
Hollon, S. D. (2003). Does cognitive therapy have an enduring effect? Cognitive Therapy and Research, 27, 71-75.

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