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Doug William December 10th, 2004 08:10 PM

Re: Is it important to change the client's dysfunctional cognitions?
Hi James---

Is it possible that the process is so hard because we don't really understand any of the most basic biological processes that underlies thought, affect, motivation and on and on. That possibly the automaticity of thought and affect are so interwined that they cannot really be separated, other than our proclivity to do so---- and that maybe when you try to change a system (the way the brain actually works) before you really understand it, that there is, by necessity, a lot of dancing in the dark?

I would enjoy a discussion that speaks about the uncertainities of cogntive therapists and what are the most pressing unanswered questions that cogntive therapists might have. And please understand I would ask exactly the same thing of any forum on this site. And believe me when I say, I have no allegiance to any particular theory or way of thinking. I am only asking if a certain kind of discussion is possible here.

What don't cogntive therapists understand yet that you think is crucial to understand about doing cogntive therapy with our patients/ clients.

Where do your uncertainities exist? Are we allowed to talk about such things?



James Pretzer January 2nd, 2005 11:01 PM

Re: What uncertainties do we face in CT/CBT?
We certainly face plenty of uncertainties when we move from reading the texts to applying CT either in clinical practice or in real-life research. It is much simpler to discuss the concepts than it is to test the theories or to make lasting changes in people's lives.

One area that is still full of uncertainty is the interface between biology and cognition. Another area of uncertainty is the exact relationship between affect and cognition (does cognition preceed emotion, does emotion preceed cognition, are they two partially independent sub-systems, ...). There's quite a bit of uncertainty about the mechanisms through which CT works (therapeutic realtionship vs specific techniques vs ...). Currently, I'm giving a fair amount of thought to another area of uncertainty, CT's approach to dealing with topics such as transference, the unconscious, and childhood trauma that traditionally have been the province of psychoanalysis (see

There are also plenty of clinical problems where we're debating which treatment protocols are most promising and how to deliver them most effectively. Even with topics as basic as CT of depression, some are arguing that "behavioral activation" is as effective as the full CT protocol and that there is no need to do Beckian CT.

There is no danger of running out of topics to research and debate in the forseeable future.

While there is plenty of uncertainty and much is left to be figured out, I'm not sure that any of this is crucial for effective treatment. I'd argue that we have good evidence that CT works well for quite a few problems. Our uncertainty lies largely in understanding the exact mechanisms through which it works, figuring out how it can be improved, figuring out how to apply it effectively with a broader range of people and problems, and figuring out how to make it available to more of the people who need effective treatment for serious problems.

Yes, certainly the uncertainties we face are a very worthwhile topic for discussion. Which uncertainties shall we talk about?

JustBen January 3rd, 2005 11:07 AM

Re: What uncertainties do we face in CT/CBT?
It's interesting that you mention the relationship between affect and cognition -- I was thinking about posting a question on that very topic. When I was first learning the basics of CT, I started with some books written for the general public. Uniformly, they presented a straightforward "thoughts precede emotions" standpoint, and when I moved on to "Cognitive Therapy: Basics and Beyond" by Judith Beck, this view was reinforced.

As I started reading casebooks and journals, however, I started finding statements like, "Of course, it's nieve to still believe that cognition always precedes emotion. The relationship between thought, affect, and behavior is complex." Somehow, though, the author never goes into more detail about this relationship.

I have three questions:

1. What is the "mainstream" view on this? Do most cognitive therapists still hold to the "thought precedes emotion" formula, or have they embraced the more "complex" view?

2. Where is the "missing link" between these two viewpoints? Earlier works seem to hold to the old formula, and newer works seem to make the case for the "complex relationship" as if it's a well-established viewpoint, but where and when did this new viewpoint emerge? (I can't seem to find it in the literature. Admittedly, my resources are kind of slim.)

3. If one believes that emotion precedes thought, then what possible benefit could be derived by challenging cognitive distortions and developing adaptive responses? Are we conceptualizing some kind of feedback loop?

Palamino January 3rd, 2005 05:59 PM

Re: What uncertainties do we face in CT/CBT?
I recommend you look at Gordon Bowers Associative Network Model, this describes an interconnected system of feelings thoughts and behaviors. It is just another way of looking at how emotional networks can drive info processing, but cognitive behavioral therapy adresses this by targeting the cognitions and or behaviors.


James Pretzer January 4th, 2005 09:47 AM

Uncertainties about the interface between thought and emotion
  1. The straightforward "thought preceeds emotion" model is a common misunderstanding or oversimplification of CT's view. What Beck really says is that the brain is constantly and automatically appraising perceived stimuli. These appraisals (aka "automatic thoughts") elicit emotional and behavioral responses. However, the chain of events doesn't stop at that point. The individual's mood biases cognition in mood-congruent ways. This tends to result in additional mood-congruent thoughts which elicit additional emotional and behavioral responses, ... ad infinitum.

    A good example is Beck's discussion of "the downward spiral of depression." Negative automatic thoughts tend to elicit a depressed mood, a depressed mood tends to bias perception and recall in a way that results in vigilance for negative experiences, enhanced recall of prior negative experiences, and a more pessimistic outlook. This tends to result in additional negative thoughts, which tend to elicit more of a depressed mood, ...

  2. Beck has endorsed a more complex view than "thoughts cause feelings" at least since the early 1970's if not longer. However,some authors have misunderstood his view and some have presented the model more simplistically when writing for non-professional audiences.

    Debate over whether cognition always preceeds emotion heated up when Zajonc published a major article in the early 1980's that seemed to provide empirical evidence that emotional responses occurred before cognitive responses did and some interpreted this as contradicting CT. Actually, Zajonc's research didn't show that emotional responses preceed cognitive responses, it showed that simple appraisals such as good/bad or threat/non-threat can occur before a stimulus is fully perceived and can elicit emotional responses. This is an interesting finding but is doesn't contradict CT. I'm not aware of any solid evidence that emotion precedes appraisal in clinically-relevant situations.

  3. If emotion really did preceed thought, this would present a variety of conceptual problems such as "If emotion preceeds recognition and appraisal of the stimulus, then what determines the emotional response?" However, even then I'd argue that we have good evidence that cognitive interventions are useful with a variety of serious problems (especially when used in the context of a good therapeutic relationship and accompanied by experiential and behavioral interventions).


One of the shortcomings of current CT accounts of the relationship between cognition and emotion is that we tend to talk as though automatic thoughts happen in isolation, one at a time, followed by emotional responses, one at a time. In reality, a constant stream of automatic thoughts is accompanied by a constant stream of emotions, each influencing the other. We tend to talk as though it is simply a matter of thoughts causing feelings because this simplified view is easier to put into words and works well enough to lead to clinically useful interventions, not because it is a comprehensive model of the relationship between thoughts and feelings.

Micah Perkins January 10th, 2005 09:51 AM

Re: What uncertainties do we face in CT/CBT?
I firmly believe in (CBT and REBT). This belief is based upon my reading of the research and my own personal and professional experience. Even though I do believe that it is important for clients to identify and discuss their feelings,. real change (lasting change) occures when they change their thinking and actions (even though they still may not feel like it). How many times have I heard someone say 'I talked and talked and talked about it, but it was only after I realized ________ and did something about it did my life get better.'
Even though I firmly believe in CBT and REBT, they, like all psychotherapies have their limitations. The limitation may be in the theory itself , the particular client, or in the practioner using the theory. To me, there still remains a big void in how to use CBT with families (if anyone has any good books to refer me to, let me know). I think that it is important to use CBT/ REBT as a framework, but to be willing to use techniques from other theories if it is more helpful to the particular client. If leading the client to directly evaluate their thinking is not working, then we have to find other ways to help them change their thinking and actions.
Maybe someday we will find a much better way of helping others, until then, I think this is the best way.

James Pretzer January 24th, 2005 11:01 PM

Is the CT model "thoughts cause feelings"?
I have an update! Dr. Beck and I are currently updating his chapter on CT's approach to stress and stress management for the third edition of Lehrer & Woolfolk's book on stress management. This morning I updated the discussion of the relationships between cognition, emotion, and behavior. The model Beck advocates is basically:
  1. An event happens.
  2. Schemas shape perception and appraisal of the event.
  3. The "primary appraisal" is very quick (before the stimulus is fully perceived), automatic, very simple (i.e. good/bad, dangerous/not dangerous, etc.), and occurs outside of awareness.
  4. The primary appraisal elicits both the initial behavioral inclinations (fight or flight...) and the initial emotional responses. Behavioral inclinations and emotional responses are seen as being independent of each other but as being correlated because they are both elicited by the same appraisals.
  5. Secondary appraisals automatically follow the primary appraisal and provide a somewhat more sophisticated assessment of the risk or gain that the situation presents and of the individual's ability to cope with the situation. This is still a simple, quick appraisal that occurs automatically and is likely to occur outside of awareness.
  6. The secondary appraisals fine-tune or modify the initial behavioral and emotional response to the situation.
  7. The initial appraisals and resultant behavioral and emotional responses influence how the situation unfolds. In other words, the initial behavioral response (i.e.fight or flight or freezing) makes a big difference in what actually occurs and the initial emotional response makes a big difference in how subsequent events are appraised (if I'm scared I'm more likely to interpret whatever happens as a threat, if I'm angry I'm more likely to interpret it as a provocation.
  8. Subsequent thought can modify or reinforce the initial appraisals, inhibit or facilitate the behavioral inclinations, and/or lead the individual to suppress or express the emotional responses. Dysfunctional beliefs, cognitive distortions, etc. contribute to dysfunctional responses.
  9. This is not a static process with a beginning and an end. We are constantly and automatically appraising events (both external and internal) as they occur whether or not we are aware of the appraisals and their effects. Our behavioral and emotional responses to prior appraisals influence subsequenct appraisals.

Clearly this is a little more complex than "thoughts cause feelings." Note that reflective, verbally-mediated thoughts of which the individual is aware come into the picture relatively late in the chain of cognitive processes.

Doug William January 25th, 2005 08:07 PM

Re: What uncertainties do we face in CT/CBT?
Hello again James---

Thank you for your initial reply to my post and the richness of presentation you offer. I had hoped that much more discussion would be prompted in the month I've waited to reply, but obviously that's not going to happen. I've also waited this long in trying to sort out the dizzying number of issues that you've raised!!! This is my third draft of a reply, because I really can't decide how to best focus my comments!! So I've decided to go much more slowly.

When you mention the interface of biology and cognition, I consider that cognition is biology, the two cannot be separated, but that's exactly the whole problem. We can keep 'saying' cognition this, affect that-- but it 'is' biology, not separate from it. We try the best we can to believe this is 'separate' from that but it isn't. It is our efforts to keep teasing things apart, or make chapter headings out of our psyche that leads us astray so much. It's a great teaching tool, but a real conceptual problem too. And in our 'verbal' arguments and verbal reasoning to make sense of it all, we, I think end up in a self-delusional mess. Affects, emotion, language development, memory, perception, learning, motivation, conscious thought, consciousness etc., each of these 'academic' areas in their own right yield tons of new questions and each specialist in each area go their own way We 'think' when we give any one these areas primacy and develop theories around them that we are progressing. I'm not so sure. And I'm not sure that the manner of research we use, clarifies as much as we think. Any historian of psychoanalysis or the behavior therapies (beginning with classical or operant treatments) and lots of other therapies where earnest efforts at research were made have revealed similar and somewhat amusing trends. First there is glowing optimism, and signs of high rates of success appear in the journals, disciples proliferate, as do training institutions. Then efforts are directed to make the theory and methods more and more inclusive, and more and more ideas are drawn in so the theorizing becomes more inclusive as well.

Then over time there is a dimming of enthusiasm and new ideas take over. Not progress mind you, but new ideas, new proliferations.

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. I'll stop here.

Thanks for the opportunity!


James Pretzer January 26th, 2005 10:52 AM

Is "cognition" necessarily verbal and conscious?
You write "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?"

In this statement you seem to be talking as though cognition is restricted to "conscious language." Beck defines cognition much more broadly than this. In fact, he asserts that the cognition involved in both "primary appraisal" and "secondary appraisal" is automatic, operates outside of conscious awareness, and isn't necessarily verbally mediated. For example, if you are out walking in the woods one day, turn a corner, and find a bear standing in front of you, you probably will not have words running through your mind saying "Oh my goodness! A bear! It will eat me! I must run away!" Instead, you will quickly and automatically appraise the situation, conclude that the bear presents a threat, conclude that "flight" is more promising than "fight" and act on this behavioral inclination. You will also feel afraid.

These appraisals are based on your schema about bears, woods, and hikers and if your schema is erroneous in some ways, your appraisal and subsequent responses are likely to be dysfunctional.

Most people assume that one feels afraid and therefore runs away. However, Beck argues that the affect and the behavioral inclination are two independent products of the appraisal of the situation. Afterall, humans are quite capable of being afraid but not running away or of running away even though they are not afraid.

CT includes non-conscious appraisals, mental imagery, and "conscious language" as different aspects of cognition, we do not limit ourselves to just addressing conscious language.

Doug William January 26th, 2005 06:21 PM

Re: What uncertainties do we face in CT/CBT?
To read about this nonconscious language idea is surely not what Albert Ellis presents. My understanding of the historical precedents was that psychoanalysis paid limited homage to the 'conscious thought process', and that the emergence of cognitive behavior modification was very much centered on using this very conscious thought process as the primary vehicle through which to create behavior change. This represented back then a bold attempt to get away from the mysterious ideas of the psychoanalytic 'unconscious' and the operation of equally unconscious 'defense mechanisms'. To now read about discussions of automaticity and psychological defenses and dreams, and transferences, and issue of communication within the therapy room is a bit befudddling to say the least. I'm presuming I'm going to be reading now about how all these things will reformulated into CT terms. And then there's going to be research about all this??? I can only say that anyone who has ventured into psychoanalytic literature concerning these topics knows that a never ending quagmire awaits (whether or not one believes in psychoanalytic theory or practice, the nature of therapeutic communcation and the therapeutic relationship and when and how a therapist intervenes certainly, I think, has lots of relevance for any of the 'talking' therapies). Unfortunately, this topic introduces more variables and more compexity.

So I'm confused, because while I really do appreciate this more complicated (and realistic) understanding of mental life and that thoughts are not so conscious and manipulable--- it just looks like to me that things are headed in a direction where we all sigh--- agree this is art and not science--- but keep building a whole new edifice of marginally testable ideas anyway along with new mountains of literature whose basic tenets are going to be shakey at best.

Do we have to know the theory and the inner workings to believe that or to know that "CT works". Dr. Pretzer I've heard this before. From the Family Therapists. From the Analysts. From the Operant Conditioning People. From the Gestalt therapists. The subjective evaluation that therapy 'works' (and that this is more important than theory) because my experience and my colleagues experience and research tells me so is a little troubling. This is how the whole psychotherapy enterprise has always proceeded. And similar too is the idea that all the major CT researchers happen to be CT proponents and they pronounce that CT works too!! It's an odd, but long time state of affairs that double blind studies--and really long term studies-- and a full appreciation of the innumerable interacting variables just seems to elude us.

But forgetting for a minute about cognitions and conscious or unconscious or automatic--- you circumvented my question about basic affects being present at birth and the developmental implications of conscious or unconscious thought process developing later. Doesn't this say something about the primary place of 'affect' in mental life, and whether the tail may be wagging the dog, by giving cognition primacy?


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.

James Pretzer May 23rd, 2005 09:35 PM

Long-term follow-up of CT/CBT with Panic/Agoraphobia
I recently stumbled across a study with truly long-term follow-up. Fava and his colleagues (2001) collected follow-up data on a sample of 132 patients treated for panic disorder and agoraphobia. The subjects were panic-free following 12 sessions of exposure therapy and were re-assessed 2 to 14 years following treatment (mean 8 years). According to the summary I came across, 23% had a relapse during the follow-up period while 62.1% remained in remission after 10 years. Relapse rates were higher for subjects who were younger, were more depressed, had residual agoraphobic avoidance at the close of treatment, or who were using medication concurrently with CBT.

For details see:
Fava, G. A., Rafanelli, C. Grandi, S., Conti, s., Ruini, C., Magelli, L., & Belluardo, P. (2001). Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychological Medicine, 31, 891-898.

Palamino May 30th, 2005 12:55 AM

Re: What uncertainties do we face in CT/CBT?
Read Gordon Bower, particularly his associative network is so clear and includes the important role of cognition and behavior.

Doug William September 15th, 2005 06:24 PM

Re: What uncertainties do we face in CT/CBT?
I probably should have started a new thread for this, but.........And I hope this will generate responses from other people as well as Dr. Pretzer.

In the training of therapists, is supervision still primarily conducted in the third person? That is, where the therapist reports to a supervisor in a separate office about the content of a session? Throughout my training this often seemed so odd, because in most every other trade the apprentice both has the opportunity to observe his teacher or mentor, and the mentor has the opportunity to directly observe and guide the student or apprentice. In a profession where so much communication takes place outside the literal utterance of words on both the therapist's part and the patient's part, I have always been puzzled by the supervisors distance from the actual treatment and the assumption that progress can adequate determined in this way. Since it it clear from all the postings here that CBT is not simply a technology to be followed or a checklist to be followed, is anything happening to improve the training of therapists. I am sure I am not the only one to have wondered about this, but I rarely read about other training models. Of course, I understand that the typical supervisory model is the most time effective and I guess cost effective system to follow--- has a combination of supervisory methods been tried?? And I'm talking about a sustained supervision where the supervisor is always in the therapy room? Psychodynamic training programs always had their reasons for not doing this- although for training purposes these reasons never made sense to me.



James Pretzer September 23rd, 2005 10:06 PM

Supervision in CT/CBT?
There are real drawbacks to basing supervision on the supervisee's description of a therapy session. The supervisor only hears about the things the supervisee noticed, remembered, and is willing to report. Obviously, this could mean that the supervisor misses out on important information. The supervisor also has limited opportunity to independently evaluate the supervisee's conceptualization, treatment plan, and interventions because all the data is filtered through the supervisee.

An apprenticeship model where the supervisee sits in and observes sessions the supervisor is conducting and where the supervisor sits in on sessions the supervisee is conducting, is not a bad concept (I think Dave Burns wrote a chapter on supervision based on this model). Unfortunately, in real life this would take a lot of time (and thus be expensive) and would be a real scheduling headache in most settings. Also, having a third party sitting in the room can really distort the therapist-client interaction.

There are other solutions that are more practical. Often the easiest way for the supervisor to model the desired behavior and to observe the supervisee's behavior is to review recordings of sessions. Supervisor and supervisee can review and discuss videos (or audio recordings) of the supervisor or other experienced therapists doing CT and can review recordings of the supervisee's sessions. This provides more detailed (and less biased) data that the supervisee's description of the session.

One can also observe live sessions through one-way mirrors or closed-circuit TV but this ends up being more time-consuming and more of a scheduling problem that reviewing tapes. An advantage of observing live sessions is that the supervisor can potentially coach the supervisee during the session. I've seen this done through the use of a "bug-in-the-ear" (i.e. an earpiece that relays the supervisor's instructions) or by phoning the supervisee during the session. I've also seen it done by having the therapist stop half-way through the session to step out of the room and consult with the supervisor. From what I've seen, each of these methods seems somewhat disruptive and I'm not sure they add much.

I do find that reviewing videos adds a lot.

Doug William September 27th, 2005 10:14 PM

Supervision: The Student's Point of View
Students Out There!!!

Please read the last two posts in this thread. This is a topic that should be close to all of your hearts!!!

What do you think about this subject-- especially for those of you going through supervision now?


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